Mansfield Place

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure that each resident received adequate supervision and was protected from avoidable accident hazards. Specifically, the facility failed to prevent a resident (Resident #58) from being struck by a tray cart pushed by a CNA, which caused the resident to fall, sustain multiple traumatic brain injuries, require emergency medical intervention, and ultimately resulted in the resident's death. Resident identifier: #58 Facility Census:56 This failure placed all residents who ambulate or are present in high-traffic hallways at risk for serious harm, injury, or death due to unsafe transportation of tray carts. Findings Include:Record Review of Incident on [DATE]:On [DATE] at 6:17 PM, Resident #58 was observed via camera footage sitting in a chair at the nurse's station. [...]

Inspectors wrote609 Based on staff Interviews, Record review and Policy review the facility failed to report possible abuse allegations to state agencies within the two hours time frame. This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #1 Facility Census: 56 This standard was NOT MET as evidenced by: Based upon Staff and Resident Interviews, Record review and Policy review the facility failed to notify State Agencies of the abuse allegation with in the two hours times frame per the CMS guidelines.

Inspectors wroteF0880S483.80 Infection Control The facility must 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. This Standard is NOT MET as evidenced by: Based upon Random observation of lunch cart and Staff Interview, the facility failed to maintain a clean and sanitary transportation of resident meals on tray carts. During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. There was also a Styrofoam cup on top of cart that was next to the spoon, intended for a resident meal. Census:56Finding include: 07/22/2025 12:40 PM Observations:During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to follow orders to release Resident #7 from the seat belt every two (2) hours. This was a random opportunity for discovery during the Long Term Care Survey. Resident identifier: #7 Facility Census:

Inspectors wrote637 Based on record review and staff interview, the facility failed to do a change in condition Minimum [NAME] Set (MDS) after resident #9 developed a pressure ulcer, and correctly documented on the MDS from 6/26/25 the status of Resident #9's injuries. This failed practice was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #9 Facility Census: 56Findings include: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately . This failed practice was found true for 2 of 5 residents reviewed for the PASRR care area during the Long Term Care Survey. Resident Identifier: #2 and #23 Facility Census:

Inspectors wrote657 Based on staff Interviews, Record review and Policy review the facility failed to follow established care plan and order of the resident and ensure they were checked on every two hours . This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #7 Facility Census: 56This standard of care was NOT MET as evidenced by:

Inspectors wroteBased on Record review and Staff interview, the facility failed to maintain medical records on each resident by not noting residents received Pharmacy Reviews/ Recommendations for the month of June, 2024. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the long term care facility. Facility Census: 56 Findings Include: During Record review on 07/23/25 it showed residents did not have a Pharmacy Recommendation or review for the month of June, 2024. for Resident's #2, #6, and #18. During an interview with the Director of Nursing (DON) on 07/23/24 at 10:00 AM who stated ( I think that was around the time i took this position and they were done i have the list, i just did not note it in the resident's chart. [...]

Inspectors wroteBased on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-determination through support of resident choice regarding having access to the dining room during meals and activities. This failed practice had the potential to affect an unlimited number of residents currently residing in the facility. Facility census: 45.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This failed practice had the potential to affect an unlimited amount of residents residing in the facility. Resident Identifiers: Resident #11. Facility census: 64.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to dispose of expired food items. The facility also failed to accurately document the nourishment room refrigerator temperature log. This failed practice had the potential to affect all residents currently receiving nourishment from the nourishment room and the Resident's food storage refrigerator. Facility census: 45.

Inspectors wroteBased on facility documentation and staff interview the facility failed to have required members attend and participate in the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 45.

Inspectors wroteBased on observation and staff interviews, 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. During an observation during the noon meal, resident hand hygiene was not performed. This had the potential to affect more than a limited number of residents. Facility census: 45.

Inspectors wroteBased on facility documentation and staff interview, the facility failed to re-evaluate Resident #27's ability to remove a physical restraint easily. This is true for one (1) of one (1) reviewed for restraints, during the long-term care survey process. Resident I identifier: #27. Facility census: 45.

Inspectors wroteBased on record review and staff interview, the facility failed to transmit a discharge assessment with the Assessment Reference Date (ARD) of 05/02/23 for Resident #14. This was true for one (1) of three (3) discharges reviewed during the survey process. Resident identifier: #14. Facility census: 45.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan regarding an actual fall with injury and discontinued medications for Resident #34. This was true for one (1) of 5 (five) residents reviewed under the care areas of accidents and unnecessary medications during the survey process. Resident identifier: #34. Facility census: 45.

Inspectors wroteBased on medical record review, family interview and staff interview, the facility failed to provide care required to maintain good hygiene to a resident who was dependent for Activities of Daily Living (ADL) care one (1) of one (1) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #36. Facility census: 45.

Inspectors wroteBased on observations, medical record review, family interview and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to follow physician orders for Resident #36 to be up in a wheelchair daily and Resident #36 Restorative nursing three (3) times a week. This was true for one (1) of 12 residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: Resident #36. Facility census: 45.

Inspectors wroteBased on observation and staff interview, the facility failed to dispose of expired medications stored in the medication room. This was a random opportunity for discovery. Facility census: 45. a) Medication Room On 10/03/23 at 10:00 AM, a tour of the medication room was completed. Within the over-the-counter medications, two (2) bottles of Oyster Shell Calcium 500 mg (milligram) plus Vitamin D were found to be expired in July 2023. On 10/03/23 at 10:06 AM, the Director of Nursing (DON) was notified and confirmed the two bottles were expired.

Inspectors wroteBased on observation, interviews, record review and policy review the facility failed to ensure bottles of insulin vials were locked and secured in a medication cart. This was a random opportunity for discovery. The failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #2, #23, #34 and #39. Facility census: 42.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the ice machine was in good, clean working order. In addition, the facility failed to ensure opened food items included the date opened by the facility staff. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 42.

Inspectors wroteBased on policy review and staff interview, the facility failed to update the pneumonia policy in accordance with national standards of practice. The policy does not address the current recommendations for the administration of the Pneumococcal conjugate vaccine (PCV) 15 and 20. This failed practice had the potential to affect more than a limited number of residents Facility census: 42.

Inspectors wroteBased on observation and staff interview, the facility failed to use a barrier during a medication pass and failed to post signage on a transmission based precaution (TBP) room. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifiers: Resident #192. Facility census 42.