Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Grove Manor during CMS and state inspections, most recent first.
The facility did not ensure that food was served at safe and appetizing temperatures, resulting in repeated resident complaints about cold and unpalatable meals. Observations showed that food temperatures dropped significantly during tray delivery, and staff confirmed that plate warmers were not used due to safety concerns. The facility's policy requiring hot foods to remain above 135°F was not followed.
A resident with chronic ischemic heart disease and CHF did not receive a timely cardiology appointment as ordered, despite ongoing symptoms and repeated documentation of the need for specialist follow-up. Staff interviews confirmed that after initial attempts to refer the resident, no further action was taken to ensure the appointment was scheduled, resulting in a lapse in care coordination.
The facility failed to provide residents with adequate hot water in their bathrooms, affecting three residents. Despite installing a new hot water heater, issues persisted with the system, including a malfunctioning thermostat and a seized mixing valve. Residents reported dissatisfaction with the water temperature, and observations confirmed that the water was not reaching appropriate temperatures. There was also a lack of documentation for water temperature checks in the affected rooms.
The facility failed to provide timely wound care treatment for three residents. A resident with an abrasion on the buttock experienced a delay in treatment and a dermatology appointment. Another resident with a venous ulcer and a third resident with a Stage II pressure ulcer also faced delays in receiving ordered treatments. These issues were confirmed by the ADON and DON, highlighting non-compliance in wound care management.
The facility failed to store food safely and maintain cleanliness in the kitchen. Boxes of food were improperly stored on the floor of a walk-in cooler, and unsanitary conditions were observed in the dish room and under the steam table. These actions were contrary to the facility's policies on food storage and cleaning.
The facility failed to maintain a pest-free environment, affecting all 67 residents. Observations revealed gnats and flies in the kitchen and flies on a resident. The Dietary Manager and Administrator confirmed these findings. The facility's Pest Control Policy acknowledges the importance of pest control, yet deficiencies were noted under specific complaint numbers.
A resident with a history of knee and hip prosthesis issues experienced a leg injury while being assisted to the bathroom, resulting in a femur fracture. Despite the incident being witnessed and the resident receiving pain medication, the facility failed to document or investigate the injury, violating their policy on handling injuries of unknown origin.
The facility failed to ensure food temperatures were assessed and recorded to maintain safe ranges before resident consumption, affecting all 64 residents. Residents reported issues with food temperature and quality, and staff confirmed daily complaints. Observations revealed that only main entrees were checked for temperature, and not all items were recorded, contrary to facility policy.
A resident did not receive their prescribed Gabapentin for two days due to unavailability, despite the medication being in the emergency kit. The facility failed to document the missed doses or notify the pharmacy or physician, violating their medication error and emergency service policies.
The facility failed to provide mechanically altered diets as ordered for three residents with specific dietary needs. Despite physician orders for mechanical soft diets, regular texture meals were prepared. The issue was identified when a surveyor intervened, and the Dietary Manager confirmed the error, highlighting noncompliance with the facility's therapeutic diet policy.
The facility failed to provide meals that honored the dietary preferences and allergies of three residents on mechanically altered diets. Despite specific dietary needs, meals served included unsuitable items like spaghetti with tomato sauce. One resident, allergic to tomatoes, was not offered an alternative meal. Interviews confirmed the meals did not align with dietary restrictions or preferences, violating the facility's policy on therapeutic diets.
The facility failed to ensure mail was delivered to residents on Saturdays, affecting nine residents and potentially impacting all 70 residents. The business office, where mail was delivered, was closed on Saturdays, causing delays in mail distribution by the activities department.
The facility failed to ensure proper disposal of garbage and refuse, with trash scattered around two exterior dumpsters. The Dietary Supervisor confirmed the debris and mentioned issues with raccoons.
The facility failed to maintain comfortable sound levels, with a loud alarm at the nursing station causing disruption and annoyance to residents. Despite ongoing complaints and acknowledgment from the Administrator, no effective measures were taken to address the issue.
The facility failed to ensure residents were offered or assisted in attending scheduled activities, affecting six of nine residents reviewed. On one occasion, five residents were left without scheduled activities, and a resident with dementia was not reminded or assisted to attend a BINGO activity.
The facility failed to ensure the activities program was directed by a qualified individual. The Activities Director did not have the necessary certification, experience, or education, and no specific training program or start date had been established. The Administrator confirmed the AD's lack of qualifications and the recent termination of the previous activities director.
A resident with multiple medical conditions reported rough care by a nurse aide. The facility investigated but failed to identify the alleged perpetrator in the report to the State Survey Agency, contrary to their abuse policy.
The facility failed to provide a resident with bed mobility bars as ordered by a physician, despite the resident's repeated requests. The Maintenance Director confirmed the absence of grab bars and indicated that none were available in the facility.
The facility failed to ensure consistency in the advanced directives for a resident with moderately impaired cognition. The resident's medical record showed conflicting information regarding her code status, with physician orders indicating Full Code and the care plan stating DNR-CC. The inconsistency was not addressed or evaluated on an ongoing basis, as confirmed by an LPN.
A resident with asthma and bipolar disorder requested her Ventolin inhaler, but the staff failed to check the emergency medication supply and instead called the pharmacy for a refill. The facility's policy requires checking the emergency supply first, and the inhaler was available in the emergency supply.
A resident with multiple diagnoses had their antipsychotic medication Abilify incorrectly discontinued instead of increased, as ordered. The error was identified through MARs review and confirmed by staff and the resident, who reported no significant mental health changes.
The facility failed to ensure accurate documentation for a resident with a left femur fracture, diabetes, and anxiety. Orders for wound care, podus boots, and liquid protein were not properly documented, and an order for surgical site cleansing was not discontinued after healing. Nursing staff confirmed these inaccuracies.
Failure to Maintain Palatable and Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at appropriate temperatures, as required by facility policy. Resident council meeting records indicated ongoing dissatisfaction with the quality of food, specifically noting repetitive menus, dry meat, and lack of seasoning, with no resolution documented. Interviews with residents revealed that breakfast was consistently served cold, leading at least one resident to stop eating breakfast altogether, despite reporting the issue to CNAs. Another resident reported that food was frequently cold by the time trays were delivered, and although she continued to eat due to hunger, she preferred warmer meals. Observations confirmed that while food temperatures were within acceptable ranges when initially measured in the kitchen, significant drops occurred during tray transport and distribution. By the time the last tray was served, food temperatures had fallen well below the required 135 degrees Fahrenheit, with sausage patties at 101 degrees and waffles at 88 degrees. Test trays were found to be lukewarm, dry, and unappetizing. The Dietary Manager acknowledged the issue, noting that plate warmers were not being used due to safety concerns and that necessary protective gloves had not been procured. The facility's policy mandates that hot foods remain above 135 degrees Fahrenheit during holding and plating, a standard that was not met during the survey.
Failure to Schedule Timely Cardiology Appointment for Resident with CHF
Penalty
Summary
The facility failed to ensure that a resident with chronic ischemic heart disease and acute diastolic congestive heart failure (CHF) received a timely cardiology appointment as ordered by the physician. Medical record review showed that after experiencing shortness of breath and chest pain, the resident was evaluated by a nurse practitioner, who ordered an EKG and a follow-up with a cardiologist. Although the facility faxed a consultation request to cardiology, there was no evidence that an appointment was scheduled or that the resident was seen by a cardiologist over a period of several months. Interviews with the resident, transportation aide, and Director of Nursing confirmed that the cardiology appointment had not been made, despite ongoing symptoms and physician orders. The transportation aide noted previous issues with missed appointments and acknowledged that no further attempts were made to schedule the cardiology consult after the last fax. Facility policy required staff to schedule and arrange transportation for medical appointments, but this process was not completed for the resident in question.
Inadequate Hot Water Supply in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that residents had access to water at appropriate temperatures in their bathrooms, affecting three residents. The issue began when the hot water heater for one resident's room malfunctioned, leading to the installation of a new hot water heater. However, the new system experienced multiple issues, including a frequently tripping high limit switch and breaker, a burnt-out heating element, and a malfunctioning thermostat. These problems persisted over several weeks, resulting in inconsistent water temperatures in the affected residents' rooms. Interviews with the residents revealed their dissatisfaction with the water temperature, as they were unable to take warm baths or showers. Observations confirmed that the water temperatures in the residents' rooms were below the appropriate levels, with temperatures dropping after initially reaching a warm state. The maintenance supervisor verified that the water temperatures were controlled by the same hot water tank and discovered that the mixing valve was seized, preventing proper adjustment. Additionally, there was no documentation of water temperatures being checked in the affected rooms since October, indicating a lapse in monitoring and maintenance.
Delayed Wound Care Treatment for Residents
Penalty
Summary
The facility failed to ensure timely implementation of treatments for three residents with wounds. Resident #3, who was cognitively intact, had an abrasion on the buttock identified on 11/06/24, but the treatment was not initiated until 11/13/24, and a dermatology appointment was delayed until 12/09/24. The resident expressed that the area was sore, and the delay in treatment and appointment was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). Resident #6, also cognitively intact, had a venous ulcer on the right lower extremity identified, but the treatment was not implemented until 12/23/24, despite being ordered earlier. Similarly, Resident #7, who had severe cognitive impairment, had a Stage II pressure ulcer on the sacrum, but the treatment was not put in place until 12/23/24. These delays in treatment were verified by the ADON and DON, indicating a pattern of non-compliance with timely wound care management.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed during a kitchen inspection. Boxes of food were found stored directly on the floor inside walk-in cooler #1, making it difficult for staff to access the cooler. Dietary Aide #134 confirmed that the boxes were left unpacked due to a recent delivery and lack of time to organize them. The facility's policy on food storage, which requires refrigerated food to be stored off the floor, was not adhered to. Additionally, the facility did not maintain cleanliness in the food service areas. Observations revealed that the shelf under the steam table was dirty with food crumbs and dried liquids, and the dish room floor near the walls had a buildup of dirt and debris. The bottom shelf of the clean dish rack was also covered in dust. Dietary Manager #119 verified these unsanitary conditions. The facility's cleaning task list and policy on cleaning and sanitation require daily cleaning of the dish room and equipment, as well as weekly dusting of pot and pan shelves, which were not followed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, which had the potential to affect all 67 residents. During an observation in the kitchen's dishwasher room, at least four to five gnats and a fly were noted, and a fly was also observed in the kitchen serving area. This was confirmed by the Dietary Manager. Additionally, a resident was observed with five flies flying off of him when he moved, and another resident reported frequent flies in his room. The Administrator confirmed the presence of flies in the resident's room and removed a bag of garbage, although no flies were observed near it. The facility's Pest Control Policy, dated August 2016, acknowledges the importance of pest control in maintaining a safe living environment, yet the deficiency was noted under Complaint Numbers OH00158146 and OH00157659.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which is a violation of their policy on abuse, neglect, mistreatment, exploitation, and misappropriation. The resident, who had a history of knee and hip prosthesis issues, was admitted to the facility and was at high risk for falls. On a particular day, the resident experienced a leg injury while being assisted to the bathroom by a CNA, resulting in intense pain. Despite the incident being witnessed by a registered nurse and the resident receiving pain medication, there was no documentation of the incident in the resident's medical record or the facility's incident and accident log. Interviews with the resident's family and staff revealed that the resident's leg was twisted during the bathroom assistance, leading to a femur fracture that was not present upon admission. The orthopedic nurse confirmed that the fracture was identified during a post-operative appointment, and the facility was instructed to send the resident to the hospital for treatment. The Director of Nursing and the Administrator acknowledged that no investigation was initiated into the incident, mistakenly believing the fracture was present on admission. This oversight represents a failure to adhere to the facility's policy requiring immediate reporting and investigation of injuries of unknown source.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were assessed to maintain safe ranges before resident consumption, potentially affecting all 64 residents receiving meals from the facility kitchen. The deficiency was identified through a review of the facility menu, resident and staff interviews, observations, and examination of the facility's food temperature logs and policy. Residents reported that hot food items were sometimes not hot enough, and staff confirmed hearing daily complaints about food temperature and quality. During an observation, it was noted that a staff member checked the temperatures of only the main entrees and did not record these temperatures or check other items on the steam table, including milk. The facility's policy on food preparation and storage, revised in November 2022, outlined that food temperatures should be maintained above 41 degrees Fahrenheit and below 135 degrees Fahrenheit to prevent the growth of pathogenic microorganisms. However, the staff did not adhere to this policy, as they failed to monitor and record the temperatures of all food items, including potentially hazardous foods like milk, throughout the meal service. This oversight was confirmed by the Dietary Manager, who acknowledged that all food items should have been checked and recorded to ensure they were at safe temperatures.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident who did not receive their prescribed medication, Gabapentin, for two consecutive days. The resident, who was cognitively intact and had diagnoses including parkinsonism, bipolar disorder, osteoarthritis, and depression, was supposed to receive Gabapentin 600 mg three times daily. However, the medication was not administered on two consecutive days because it was not available in the facility. Despite the availability of Gabapentin in the emergency kit, there was no evidence that it was used to provide the missed doses to the resident. The facility's progress notes and interviews confirmed that the resident missed six doses of Gabapentin over the two days, and there was no documentation of notification to the pharmacy or attending physician about the missed doses. Additionally, the facility's emergency kit log showed no record of Gabapentin being signed out for the resident. The facility's policies on medication errors and emergency pharmacy services were not adhered to, as there was a lack of documentation and failure to administer the medication as ordered.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to provide mechanically altered diets as ordered by physicians for three residents, leading to a deficiency. Resident #11, diagnosed with Alzheimer's disease, oral phase dysphagia, muscle weakness, and complete loss of teeth, was ordered a mechanical soft diet. Resident #16, with malnutrition, dementia, aphasia, dysphagia, and edentulous, was ordered a no added salt mechanical soft texture diet. Resident #18, with a history of cancer, asthma, schizoaffective disorder, GERD, and mild intellectual disabilities, was also ordered a mechanical soft diet. Despite these orders, the facility prepared regular texture meal trays for these residents, which included chicken parmesan with spaghetti, cauliflower, and garlic toast. The deficiency was identified when a surveyor observed the meal preparation and intervened before the meals were served. The Dietary Manager confirmed that the meals prepared did not match the mechanically altered diet orders for the residents. The facility's policy on therapeutic diets, which requires adherence to physician orders for diet modifications, was not followed. This oversight was documented under Complaint Number OH00155626, indicating noncompliance with dietary requirements for residents with specific dietary needs.
Failure to Honor Dietary Preferences and Allergies
Penalty
Summary
The facility failed to provide meals that honored the dietary preferences and allergies of three residents on mechanically altered diets. Resident #11, diagnosed with Alzheimer's disease and oral phase dysphagia, required a mechanical soft diet due to being edentulous and at risk for malnutrition. Resident #16, with malnutrition and dysphagia following a cerebral vascular accident, also required a mechanically altered diet with no added salt. Resident #18, with a history of cancer and an allergy to tomatoes, was similarly on a mechanical soft diet. Despite these dietary needs, the facility served meals that did not accommodate these requirements. On a specific observation, the Dietary Manager prepared meals that included spaghetti with tomato sauce, which was unsuitable for the residents involved. Resident #18, allergic to tomatoes, was unable to eat the meal provided and was not offered an alternative. Interviews confirmed that the meals did not align with the residents' dietary restrictions or preferences, as indicated on their tray tickets. The facility's policy on therapeutic diets, which should align with physician orders and resident preferences, was not adhered to, leading to this deficiency.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays, affecting nine residents who were interviewed and potentially impacting all 70 residents in the facility. During a Resident Council meeting, residents expressed concerns that mail delivered to the business office on Saturdays was not distributed within 24 hours. The business office was typically closed on Saturdays, and the activities department, responsible for mail distribution, had to wait until the business office reopened to sort and distribute the mail. This delay was confirmed by an Activities Assistant, who verified that mail received on Saturdays was not normally delivered the same day.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 70 residents. During an observation, two exterior facility dumpsters were found with trash scattered around them, including various food wrappers, containers, a used brief, and a disposable glove. Unidentified animal track marks were also observed near the dumpsters. The Dietary Supervisor confirmed the presence of the debris and mentioned that the facility had issues with raccoons.
Failure to Maintain Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain comfortable sound levels, affecting nine residents who voiced concerns about the loud alarm at the nursing station. Observations on 05/15/24 identified a very loud alarm that sounded whenever the door to the patio was opened. This alarm, located at the front of the nursing station, was heard multiple times in a short period, causing annoyance to residents nearby. Interviews with residents confirmed that the alarm was disruptive, waking them up from sleep and being a frequent topic of complaint at Resident Council meetings. The Maintenance Director confirmed that the alarm could not be turned down or off and that there had been ongoing complaints from residents about the noise. The facility's concern log showed resident complaints about the loud alarm dating back to January 2024. The Administrator acknowledged being aware of the residents' concerns and mentioned that a company had assessed the alarm system but found no way to reduce the sound. Despite these complaints and the apparent disruption caused by the alarm, no effective measures had been taken to address the issue, leading to the deficiency noted in the report.
Failure to Ensure Resident Participation in Scheduled Activities
Penalty
Summary
The facility failed to ensure residents were offered or assisted in attending scheduled activities, affecting six of nine residents reviewed. On 05/15/24, five residents were observed sitting in the dining area where a detective activity and a daily walk were scheduled to take place, but no staff were present, and no activities occurred. Residents reported that it was not uncommon for scheduled activities to be canceled without notice. The Activities Director confirmed that the activities did not occur as scheduled, and the Administrator acknowledged that staff should have informed residents of the changes. Additionally, Resident #46, who has dementia and requires reminders and assistance to participate in activities, was not reminded or assisted to attend a scheduled BINGO activity on 05/14/24. Despite BINGO being scheduled and taking place in the dining room, Resident #46 was observed lying in her bed and was not informed or assisted by staff to attend. Interviews with staff revealed a lack of clarity on whose responsibility it was to assist residents in attending activities, contributing to the resident's non-participation.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified individual as required. The Activities Director (AD) did not have the necessary certification, experience, or education to hold the position. This was confirmed through personnel file review, staff interviews, and a review of the job description. The AD acknowledged the lack of qualifications and stated that the facility planned to provide training, but no specific training program or start date had been established. The Administrator confirmed the AD's lack of qualifications and the recent termination of the previous activities director. The facility census was 70, with two residents identified as not participating in activities.
Failure to Identify Alleged Perpetrator in Abuse Report
Penalty
Summary
The facility failed to ensure alleged perpetrators were identified in reports of abuse allegations submitted to the State Survey Agency. This deficiency affected a resident who had been admitted with multiple medical diagnoses including non-stemi myocardial infarction, anemia, hypertension, generalized weakness, depression, obesity, and hypokalemia. The resident reported that a nurse aide was rough with her care, and although the facility conducted an investigation and asked her questions, they omitted the alleged perpetrator in the report submitted to the State Survey Agency. The Social Services Director confirmed the omission, which was against the facility's abuse policy that required immediate investigation and thorough documentation, including identifying all persons involved.
Failure to Provide Bed Mobility Bars for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences to enhance self-mobility. Resident #71, who was admitted with diagnoses including morbid obesity, congestive heart failure, high blood pressure, diabetes, and chronic kidney disease, required partial/moderate assistance with rolling and had a physician's order for bilateral bed mobility bars. Despite the resident's repeated requests and the physician's order dated 04/13/24, the grab bars had not been installed by 05/15/24. The Maintenance Director confirmed the absence of grab bars and indicated that none were available in the facility.
Inconsistent Advanced Directives for Resident
Penalty
Summary
The facility failed to ensure consistency in the advanced directives for one resident, identified as Resident #38. The resident's medical record showed conflicting information regarding her code status. While the physician orders dated 03/25/24 indicated that the resident was to be a Full Code, the current plan of care stated that the resident wished to have a Do Not Resuscitate - Comfort Care (DNR-CC) status. This inconsistency was not addressed or evaluated on an ongoing basis, as confirmed by an interview with an LPN who could not find any evidence of such evaluations. Resident #38, who was admitted to the facility on 09/18/20, had medical diagnoses including congestive heart failure, edema, pain, morbid obesity, and diabetes. The resident was assessed with moderately impaired cognition according to the most recent Minimum Data Set (MDS) assessment. During an interview, the resident explicitly stated that she did not want life-saving measures performed in the event of cardiac or respiratory arrest. Despite this, the physician orders and care plan were not aligned, leading to a deficiency in honoring the resident's advanced directive wishes.
Failure to Provide As-Needed Medication from Emergency Supply
Penalty
Summary
The facility failed to provide an as-needed medication from the emergency supply for a resident with asthma and bipolar disorder. The resident, admitted on 10/19/17, requested a respiratory assessment on 05/14/24, which showed no concerns. However, the resident later requested her Ventolin inhaler and was informed that it was not available. The nurse called the pharmacy for a refill, which was scheduled to be delivered later that evening. The resident expressed concern about the unavailability of her medication when needed. An interview with an LPN confirmed that the staff did not check the emergency medication supply for the Ventolin inhaler, as they should have, and instead called the pharmacy. The facility's emergency medication policy requires staff to check the emergency supply and use it if the medication is not available in the medication cart. A review of the facility's emergency medication list confirmed that a Ventolin inhaler was available. This deficiency was investigated under Complaint Numbers OH00153898 and OH00152383.
Medication Error Leading to Discontinued Antipsychotic
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. Resident #59, who had multiple diagnoses including type two diabetes, chronic obstructive pulmonary disease, major depressive disorder, and unspecified dementia, had a physician's order to increase the dosage of the antipsychotic medication Abilify from 2 mg to 5 mg. This order, dated 04/22/24, was received and acknowledged by an LPN but was inadvertently discontinued instead of being transcribed correctly. As a result, the increased dosage of Abilify was not administered from 04/23/24 to 05/15/24, as evidenced by the medication administration records (MARs) for April and May 2024. A certified nurse practitioner (CNP) noted on 05/10/24 that the Abilify dosage was supposed to be increased but had been discontinued instead. The CNP documented that the medication would be restarted. Interviews with another LPN and Resident #59 confirmed the medication error. The resident reported no significant changes in mental health due to the error. This deficiency was investigated under Complaint Number OH00153898.
Inaccurate Documentation of Wound Care and Supplement Orders
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for Resident #66, who had diagnoses including a displaced fracture of the left femur, diabetes mellitus, and anxiety. The physician's orders included cleansing the surgical site on the left hip, using podus boots for heel pressure injury prevention, and administering house liquid protein for wound healing. However, the medication administration record (MAR) and treatment administration record (TAR) revealed that the podus boots were not documented as being used on specific dates, and the house liquid protein was not documented as administered on several consecutive days in May 2024. Additionally, the order to cleanse the surgical site was documented as completed daily even after the site had healed by the end of March 2024, indicating that the order should have been discontinued but was not, leading to inaccurate documentation of a treatment that was no longer necessary. Interviews with nursing staff confirmed these documentation inaccuracies and the failure to discontinue the order for the surgical site cleansing. This deficiency was identified during an investigation under Complaint Numbers OH00153898 and OH00152383. The failure to accurately document wound care treatments, prevention devices, and supplement orders affected Resident #66, highlighting lapses in the facility's adherence to professional standards for maintaining medical records. The nursing staff's inability to accurately document and discontinue orders as needed contributed to the deficiency, impacting the quality of care provided to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Mifflin | 0 mi | ★★★★★ | 0 | 0 |
| Jag Healthcare Mansfield | 4.3 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 4.6 mi | ★★★★★ | 3 | 0 |
| Liberty Nursing Center Of Mansfield | 5 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Mansfie | 5.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.