Mansfield Medical Lodge

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry pantry area on 09/23/25.2. The facility failed to seal opened items in plastic bags in the refrigerator area on 09/23/25.3. The facility failed to seal opened items in plastic bags and boxes in the freezer area on 09/23/25.4. The facility failed to ensure to have a use by date on items in zip loc bags in the freezer area on 09/23/25.5. The facility failed to ensure the dented can in the dry storage area with the other canned food were removed from the shelf on 09/23/25. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #38 and Resident #51) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA B wore a PPE gown and performed hand hygiene during care for Resident #51.2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #38 This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Residents #93) reviewed for accident hazards. CNA D did not ensure Resident #93, who required 1:1 meal assistance, was positioned correctly while eating. This failure could place residents at risk for aspiration and choking related to eating in an improper position.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. 1. The facility failed to follow physician's order to cover Resident #1's wound with a dry dressing as needed for dislodgement of dressing on 06/03/25. 2. The facility failed to ensure Resident #1's had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/03/25. 3. The facility failed to provide wound care to Resident #2's sacral wound on 05/24/25, 05/25/25, 05/31/25 and 06/01/25. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed a stage three sacral wound and pacemaker interventions. This failure could place residents at risk of receiving inadequate interventions not individualized to their health care needs.

Inspectors wroteBased on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility for 1 of 6 residents (Resident #1) reviewed for transfer and discharged rights. The BOM failed to submit Resident #1's Long Term (Medicaid) application and provided bank statements when she and her family expressed interest in applying for Medicaid prior to her discharge from the facility on 09/12/24. This deficient practice could place residents at risk of not being able to remain at the facility, resulting in violation of their rights.

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative (s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of four residents (Resident #1) and one of one month (August 2024) reviewed for transfer and discharge. 1. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on [DATE]. 2. The facility failed to ensure the facility's Ombudsman was notified, at least 30 days in advance of the discharge, or as soon as practicable before transfer or discharge for all discharges during the month of August 2024. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored (moldy food in the fridge, food exposed to air, food on the floor) in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 08/06/24 beginning at 8:55 AM revealed: - 1 tomato with a black spot and 1 withered tomato; - 7 withered strawberries and 1 strawberry with a brownish green spots; - 5 green bell peppers with black spots; - 1 sweet potato with fuzzy green and white spots; and - 1 frozen bag of mixed berries thawing on top of a box on the second shelf from the top. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 nurses' medication carts (medication cart on 200 hall) reviewed for pharmacy services. The facility failed to discard expired glucometer control solution (used to test and calibrate the glucometer machines) from 200 hall medication cart. This failure placed the residents at risk of incorrect labeling of drugs and biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for one (Resident #14) of eight residents reviewed for enteral nutrition, in that: The facility failed to schedule a gastroenterologist consult for removal of g-tube (feeding method to deliver formula through feeding tube) for Resident #14 according to physician orders. This failure could place residents at risk for adverse reactions, health complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #71) of 4 residents reviewed for pharmaceutical services. RN A failed to follow the facility policy for administering medication through gravity when administering medications via Resident #71's g-tube. These failures could put residents who received medications via g-tube at risk for aspiration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for three (Hall 100, 200 and 400 Medication Cart) of four medication carts and one refrigerator reviewed for pharmacy services. 1. The facility failed to ensure expired medications in nurse medication carts for Hall 100, 200, 400 and refrigerator were removed and destroyed. 2. The facility failed to ensure insulin were dated with opening dates. The failure placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator and due to not putting opening date on insulin pens/vials.