Mansfield Nursing Center

Inspectors wroteBased on record reviews and interviews the facility failed to immediately notify 1 (#2) of 3 (#1, #2, and #3) sample resident's physician and/or the DON (Director of Nursing) of the significant change in a resident's physical condition. The facility failed to notify the physician and/or the DON when resident #2 had a change in condition including severe shortness of breath and an oxygen saturation level of 60%.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to accommodate the needs of 1(#8) of 20 sampled residents. The facility failed to ensure the resident was reassessed for the use assist rails. Review of Resident #8's medical record revealed Resident #8 was admitted [DATE], with a readmission date of 07/28/2025. Resident #8's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left-non dominate side and lack of coordination. Review of Resident #8's Quarterly MDS (Minimum Data Set) dated 06/08/2025 revealed Resident #8 had a BIMS (Brief Interview of Mental Status) score of 13/15, indicating intact cognition. Resident #8 had limited range of motion for both upper and lower extremities on one side. An observation on 08/11/2025 at 9:47 a.m. Resident #8's resting in bed, which did not have assist rails. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to: provide to the resident and/or the resident's responsible party (RP) written notice which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy for 1 (#74) of 2 (#74, #76) residents reviewed for transfer/discharge, and notify the State's Long Term Care Ombudsman of discharges in writing for 2 (#74, #76) of 2 (#74, #76) residents reviewed for discharge requirements.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and help prevent the development and transmission of infection for 3 (#10, #13, #79) of 3 (#10, #13, #79) sampled residents requiring EBP (enhanced barrier precautions). The facility failed to:1. Post clear signage outside Resident #10, #13 and #79's room indicating the type of precautions, required personal protective equipment and high contact resident care activities that require the use of gown and gloves,2. Have gowns, gloves and alcohol-based hand rub available outside the room for Resident #10, #13 and #79 and 3. Obtain an order for EBP for Resident #79.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice and followed facility's policies for 2 (# 60, #77) of 2 (#60, #77) residents reviewed for respiratory care. The facility failed to ensure: 1.) Oxygen cannula and tubing was changed per facility policy (Resident #60), 2.) Respiratory mask was stored per facility policy (Resident #77), and 3.) An oxygen in use sign was placed on the outside of the resident's room entrance door per facility policy (Resident #77).

Inspectors wroteBased on record review, observation, and interviews the facility failed to ensure the Controlled Drug Record was maintained and reconciled for 1 (Cart A) of 1 (Cart A) medication cart reviewed. Review of the facility's Medications - Controlled Substances Policy (undated) revealed in part:1. General Protocols:a. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel. d. All controlled substances (Schedule II, III, IV, and V) are accounted for in one of the following ways:ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.iii. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to protect the resident's right to be free from abuse of misappropriation of property and exploitation by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. S2 CNA (Certified Nursing Assistant) transferred money from Resident #1's bank account via [NAME] (bank to bank transfer) to her personal bank account. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/17/2025, thus it was determined to be a Past Noncompliance Citation.

Inspectors wroteBased on observations and interview the facility failed to ensure the most recent survey results were posted in a place readily accessible to the residents, family members or anyone to review.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure the correct use and the maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, obtaining a written order from the physician for bed rails and an informed consent from resident or resident representative prior to installation for 4 (#8, #10, #13, #37) out of 7 (#5, #8, #10, #13, #34, #37, #39) residents reviewed for accidents.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 2 (#13, #39) out of 5 (#13, #14, #37, #39, #60) residents reviewed for unnecessary medications. The facility failed to monitor Resident #13 for side effects while receiving an antidepressant and Resident #39 for side effects while receiving antidepressant and antianxiety medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 1 (#39) out of 5 (#13, #14, #37, #39, #60) residents reviewed for unnecessary medications. The facility failed to monitor Resident #39 for edema while receiving a diuretic.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure residents were treated with respect and dignity and cared for in a manner that promotes enhancement of his or her quality of life for 3 (#3, #17, #26) of 5 residents attending the survey Resident Council meeting. The facility failed to ensure the residents were treated with dignity and respect during activities and not being scolded or reprimanded by staff causing emotional distress.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#13) of 26 sampled residents reviewed, by failing to give medication as ordered by a physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 7 residents were observed during the facility's medication administration by 2 LPN's (Licensed Practical Nurse) on 09/25/2023 through 09/26/2023. A total of 27 opportunities were observed which included 4 errors involving 4 residents (#19, #18, #21, and #7), for a medication error rate of 14.81%.

Inspectors wroteBased on record reviews, observations and interviews the facility failed to ensure 1 resident (#52) out of 1 resident reviewed for accommodation of needs and preferences was able to move around room, reach personal items and call light at all times.