Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Mansfield Medical Lodge during CMS and state inspections, most recent first.
Unsealed and improperly labeled food items were found in the kitchen dry pantry, refrigerator, and freezer, including multiple packages and containers exposed to air, frozen items without use-by dates, and a dented can stored with other canned goods. The DM stated staff were responsible for sealing, dating, and checking food items, but she was unaware of the findings and no documentation of monthly audits was available.
Infection control lapses occurred during direct care for two residents. One resident with a supra-pubic catheter, wound-related EBP, diabetes, and MS was assisted by a CNA who wore gloves but no gown, leaned over the bed while fastening the brief, and did not perform hand hygiene after removing gloves. Another resident with a Foley catheter, stroke, and diabetes received incontinence care from a CNA who changed gloves multiple times without hand hygiene while cleaning the peri-area and buttocks, removing the soiled brief, applying barrier cream, and fastening the clean brief.
A resident with aphasia, Parkinson’s disease, stroke, hemiplegia, dysphagia, and respiratory failure required 1:1 feeding and upright positioning, but a CNA fed him while he was slumped over to the left in his wheelchair. The CNA acknowledged the resident should not have been fed in that position, and the DON stated staff needed to reposition him upright before feeding.
Two residents with pressure ulcers did not receive wound care and pressure relief interventions as ordered, including missed dressing changes, lack of documentation, and improper or missing low air loss mattresses. Care plans lacked specific wound care instructions, and staff were unclear about responsibilities, especially on weekends, resulting in inconsistent care and failure to follow professional standards.
A resident with multiple medical conditions, including a stage 3 sacral wound and a pacemaker, did not have a comprehensive care plan addressing all identified needs. The care plan lacked interventions for skin integrity and was incomplete regarding pacemaker management. Wound care was not documented on several weekends, and the resident reported inconsistent care, especially on weekends. Staff interviews revealed unclear responsibilities for care planning, and facility policies requiring measurable objectives and timeframes were not followed.
A resident with multiple medical conditions was improperly discharged from a facility after the Business Office Manager failed to submit her Medicaid application, despite the family's interest and provision of necessary documents. The BOM believed the resident would not qualify due to properties and life insurance policies, leading to the discharge without a 30-day notice. The facility's policy on handling such situations was not provided.
The facility failed to notify the Ombudsman of resident discharges, including a resident with multiple health issues discharged home without proper notification. This oversight was due to a change in social workers, with the new social worker unaware of the requirement. The lack of notification could impact residents' access to advocacy services.
The facility failed to maintain proper food storage and sanitation standards in the kitchen, leading to potential contamination risks. Observations included moldy produce, improperly thawed food, and unclean equipment. The Dietary Supervisor confirmed weekly cleaning routines and acknowledged the risks of improper food storage.
A facility failed to discard expired glucometer control solutions from a medication cart, risking inaccurate glucose readings for residents. RN B was unaware of the expired solutions, which were used for daily glucometer calibration by the 10 PM to 6 AM nurse. The DON and ADON were responsible for ensuring calibrations and up-to-date items in carts, but the expired solution was not identified until the survey. Staff interviews revealed inconsistent checks on expiration dates, despite training and policy requirements.
Unsealed and Improperly Stored Food Items in Kitchen Storage Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen’s dry pantry, refrigerator, and freezer areas. During observation of the kitchen, multiple food items were found unsealed and exposed to air in the dry pantry, including chocolate fudge icing, brown sugar, pasta noodles, macaroni, tortilla packages, instant food thickener, and a dented can of sliced salad beans. In the refrigerator, several items were also unsealed and exposed to air, including milk, salad, mozzarella cheese, orange juice, and sandwich bread. In the freezer, multiple boxes of food were observed unsealed and exposed to air, including chicken patties, beef fritter patties, flame broiled patties, and sugar frozen cookie dough. Several zip loc bags of frozen foods were labeled with dates but did not have a use-by date, including roast beef, diced turkey, sausage, scrambled eggs, m/s sausage, and cod fish. A metal pan with clear bowls of cantaloupe was covered with parchment paper and exposed to air, and a container of ricotta cheese was also unsealed and exposed to air. The Dietary Manager stated she was unaware of the unsealed items and the dented can in the storage areas. She stated all kitchen staff were responsible for ensuring food items were sealed, labeled, and checked for expiration dates, and that dented cans should be removed from the shelves and placed in her office area designated for dented cans. She also stated that monthly audits were performed, but no documentation of those audits was available in the kitchen record review. A staff member interviewed also stated she was unaware of the unsealed items and the dented can, and both interviews reflected that staff were responsible for checking storage conditions and removing items that were unsealed or improperly stored.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control. One resident had diagnoses including neurogenic bladder, diabetes, and multiple sclerosis, was dependent on staff for toileting, and was occasionally incontinent of stool. Her care plan indicated she was on EBP related to a wound and supra-pubic catheter, with interventions to use standard precautions including gowns and gloves during dressing, bathing, transferring, hygiene, changing linens, changing briefs, toileting, device care, and wound care. During an observation, CNA B was in the resident’s room wearing gloves but not a gown, leaned over the bed to fasten the resident’s brief, and her clothes touched the resident’s bed. CNA B removed her gloves, did not perform hand hygiene, put on new gloves, and straightened the resident’s blankets. CNA B stated she believed only gloves were required and said she forgot to perform hand hygiene between glove changes. A second resident had a Foley catheter, was occasionally incontinent of bladder, had diagnoses including stroke and diabetes, and required substantial assistance with toileting. Her care plan stated she was totally dependent on staff for personal hygiene. During observed incontinence care, CNA C cleaned the peri-area, changed gloves, and did not perform hand hygiene; she then cleaned the buttocks, changed gloves again without hand hygiene, removed the soiled brief without changing gloves or performing hand hygiene, placed a clean brief, applied barrier cream, changed gloves again without hand hygiene, and fastened the brief. CNA C stated she was supposed to perform hand hygiene between each glove change and had been trained to do so, but did not do it because she forgot. The DON stated staff were supposed to perform hand hygiene between glove changes and wear a gown while positioning a resident and fastening a brief who was on EBP, and that hand hygiene and proper PPE use were required to reduce the risk for infection.
Improper Feeding Position During 1:1 Meal Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during meals for Resident #93, who required 1:1 feeding assistance and maximum assistance for positioning to sit upright. The resident’s quarterly MDS showed diagnoses including aphasia, Parkinson’s disease, stroke, hemiplegia, seizure disorder, difficulty swallowing, and respiratory failure, and the care plan directed staff to provide 1:1 assist feeding, keep the resident in an upright position, and maintain the head of bed elevated during meals and afterward. During an observation, Resident #93 was seated in a custom wheelchair with his head and body slumped over the left side while CNA D fed him a chopped diet. CNA D fed the resident two bites while he remained slumped over. CNA D stated the resident was not supposed to be slumped over while eating to prevent choking, and CNA D and CNA E then removed the resident from the table and repositioned him upright. In interview, CNA D said he fed the resident while leaning to the left because that was the resident’s posture and stated therapy had told him 2-3 weeks earlier that the resident was supposed to sit up straight to eat. The DON later stated it was not okay to feed the resident while he was slumped to the left and that staff needed to reposition him upright before feeding.
Failure to Provide Consistent Pressure Ulcer Care and Pressure Relief Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection or new pressure ulcers for two residents with existing pressure ulcers. For one resident, staff did not follow the physician's order to cover a sacral wound with a dry dressing when the original dressing became dislodged. During an observation, the wound was found exposed without a dressing, and the nurse on duty was unaware that the dressing had come off. Documentation did not reflect that PRN wound care was provided as ordered. Additionally, the resident's low air loss mattress was set at a weight much higher than the resident's actual weight, and there was no recent weight recorded in the chart to guide proper mattress settings. Another resident with a stage three sacral pressure ulcer did not receive wound care as ordered on multiple dates, as evidenced by blank treatment administration records (TARs) for those days. The resident also did not have a functioning low air loss mattress for pressure redistribution, as the previous mattress was removed after it became nonfunctional and was not replaced. The resident reported that care was less consistent on weekends, and staff interviews confirmed that wound care was not always provided or documented on those days. Both residents' care plans lacked specific information about their wounds and did not address their current wound care needs. Staff interviews revealed confusion about responsibilities for wound care, especially on weekends and in the absence of a dedicated wound care nurse. The facility's own wound care policy required documentation of wound care provided, but this was not consistently done. These failures resulted in residents not receiving wound care and pressure relief interventions as ordered and as required by professional standards of practice.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Wound and Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including a stage three sacral pressure wound and a pacemaker. The care plan did not address the resident's sacral wound or other skin integrity issues, despite the presence of a physician's order for daily wound care and recommendations for pressure-relieving interventions. Additionally, the care plan section for the pacemaker was incomplete, lacking specific information such as manufacturer, model, serial number, date of implantation, and cardiologist details. Record reviews revealed that wound care was not documented as provided on several weekend dates, and the resident reported not receiving wound care on weekends, as well as a general lack of care during those times. The resident also noted the removal of a low air loss mattress, which was recommended for pressure relief, after it became nonfunctional, and it was not replaced. Interviews with staff indicated that care planning responsibilities were not consistently followed, with confusion over which staff members were responsible for updating care plans for wounds and medical devices. Facility policies required comprehensive care plans with measurable objectives and timeframes to address each resident's needs, including physical, psychosocial, and functional aspects. However, the care plan for this resident did not reflect these requirements, as it omitted critical interventions and failed to ensure continuity and documentation of care, particularly for wound management and pacemaker monitoring.
Failure to Submit Medicaid Application Leads to Improper Discharge
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #1, was not transferred or discharged without adequate reason and proper documentation. Resident #1, a female with multiple medical conditions including muscle wasting, cognitive communication deficit, and chronic kidney disease, was admitted to the facility with no plans for discharge. However, the facility did not submit her Medicaid application despite the family's expressed interest and provision of necessary documents, leading to her discharge. The Business Office Manager (BOM) did not submit the Medicaid application for Resident #1, citing that the resident would not qualify due to properties and life insurance policies in her name. The BOM stated that the facility would not submit applications they believed would not be approved. This decision was made despite the family's efforts to provide financial information and their interest in applying for Medicaid to cover Resident #1's stay. The BOM also mentioned that a 30-day notice is required for discharge after a Medicaid application is submitted, which was not done in this case. Interviews with the family and facility staff revealed that the family was in communication with the facility regarding payment options and Medicaid application. The family provided bank statements and other financial information, but the facility advised them that Resident #1 would not qualify for Medicaid. The Administrator stated that the responsibility to submit Medicaid applications fell on the resident and their families, and he was not aware that the application was not submitted. The facility's policy on handling such situations was requested but not provided, indicating a lack of clear procedural guidance.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to a resident, the resident's representative, and the Ombudsman. Specifically, the facility did not notify the Ombudsman of the discharge of a resident who was sent home with medications and personal belongings. The resident, a female with multiple diagnoses including muscle wasting, cognitive communication deficit, and dementia, was discharged without the required notification to the Ombudsman, which is a violation of the regulatory requirements. Additionally, the facility did not notify the Ombudsman of any discharges that occurred during the month of August 2024. This oversight was attributed to a change in social workers, with the new social worker being unaware of the requirement to notify the Ombudsman. The Director of Nursing and the Administrator were also unaware of the lapse in communication until it was brought to their attention. The lack of notification could potentially impact residents' access to advocacy services and their ability to appeal the discharge decision.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, preparation, and sanitation practices in the kitchen. Observations revealed moldy and withered produce, such as tomatoes, strawberries, bell peppers, and a sweet potato, stored in the refrigerator. Additionally, a bag of mixed berries was improperly thawing on a shelf. In the dry storage area, a container of ground cinnamon was left open, and an expired container of onion powder was found. The floor had a white powder substance, indicating a lack of cleanliness. Further inspection of the kitchen's open area and freezer showed an unclean grease bucket under a prep table, residue on a deep fryer, and black residue on the floor under a juice machine. The freezer contained open boxes of cookie dough, yeast rolls, and sugar cookie dough, along with ice cream cups on the floor. The Dietary Supervisor confirmed that the refrigerator was cleaned weekly, and spills were addressed immediately. She acknowledged that food should be thawed on the bottom shelf and that all staff were responsible for maintaining produce freshness. The supervisor also stated that improper food storage could lead to contamination and food-borne illnesses.
Expired Glucometer Control Solutions Found in Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not discarding expired glucometer control solutions from a medication cart on the 200 hall. This deficiency was identified during an observation and interview with RN B, who was unaware of the expired control solutions. The control solutions, used to calibrate glucometers, had an expiration date that had passed, and no open date was noted on the box. RN B stated that the responsibility for using the solutions to calibrate the glucometers daily fell to the 10 PM to 6 AM nurse. The expired solutions posed a risk of decreased efficacy, potentially leading to inaccurate glucose readings for residents. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible for ensuring that glucometer calibrations were completed and that items in the medication carts were up to date. However, the expired control solution was not identified until the survey. The DON expressed surprise at the oversight, noting that the pharmacy consultant also checked the carts. Interviews with nursing staff revealed that while they were trained to perform glucometer calibrations, they did not consistently check expiration dates on the control solutions. The facility's policy and the glucometer manufacturer's documentation both emphasized the importance of using non-expired control solutions to ensure accurate glucose readings.
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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.
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Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Creekwood | 2.1 mi | ★★★★★ | 13 | 0 |
| Avir At Mansfield | 2.8 mi | ★★★★★ | 0 | 0 |
| Matlock Place Health & Rehabilitation Center | 5.8 mi | ★★★★★ | 10 | 2 |
| Midlothian Healthcare Center | 7.5 mi | ★★★★★ | 2 | 0 |
| Midtowne Meadows Health & Rehab | 7.6 mi | ★★★★★ | 1 | 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.