Jag Healthcare Mansfield

In the surveyor’s words

From the most serious findings on record at Jag Healthcare Mansfield, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Apr 15, 2024

  Based on review of facility billing records, emails, invoices and past due notices, review of bank statements, review of the facility assessment, Nursing Home Admission Agreement, facility policy and procedures, and interviews with residents/family, staff, vendors, and company personnel, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent the actual and potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. […]

• No harm, potential for more than minimal, widespreadF725Jul 1, 2025

  Based on resident interviews, staff interviews, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 57 residents in the facility. The facility census was 57. Findings include: Interview with Resident #43 on 06/23/25 at 12:07 P.M. revealed the facility had several call offs over the weekend resulting in him not getting a shower. Observation on 06/23/25 at 12:07 P.M. revealed Resident #43 had body odor and oily hair. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. […]

• No harm, potential for more than minimal, widespreadF800Jul 1, 2025

  Based on observation and interviews, the facility failed to serve an appropriate amount of meat (protein) with the lunch meal. This had the potential to affect all residents at the facility. The facility census was 57. Findings include: Observation on 06/25/25 at 11:33 A.M. of the food service tray line revealed [NAME] #245 was serving residents meals. Observation revealed there were noodles in one pan and gravy with small chunks of beef in another pan. Observation revealed [NAME] #245 was placing the noodles with a four ounce scoop on each residents plate. The beef and gravy was served with a six ounce scoop. Observation revealed when [NAME] #245 placed the meat with gravy on each plate, some plates received one piece of stew meat, some had two and some had three pieces of meat. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based on observation, interview, and review of the facility policy, the facility failed to ensure expired food items were disposed of and not stored with other food items used for resident meals. This had the potential to affect all 57 residents residing at the facility. Findings include: Observation on 06/23/25 at 8:10 A.M. with Dietary Manager (DM) #236 revealed in walk in cooler labeled #1 there were two metal containers, one with a bulk amount of sliced ham with an expiration date of 06/11/25 that was opened and partially used. A second bag that was in the container had a bulk amount of sliced salami, partially used with an expiration date of 06/14/25. A third bag had a bulk amount of sliced roast beef, partially used with an expiration date of 06/14/25. […]

• No harm, potential for more than minimal, widespreadF868Jul 1, 2025

  Based on review of Quality Assessment and Assurance (QAA) meeting sign-in documentation, staff interview, and facility policy review, the facility failed to have required Quality Assessment and Assurance quarterly meetings with required members. This had the potential to affect all residents. The facility census was 57. Findings include: Review of the QAA sign in sheets revealed the facility had no documentation of QAA meetings for the first, second, and third quarters of 2024. The facility allowed viewing of fourth quarter QAA meeting documentation for 12/17/24 but there was no sign-in sheet for required members. […]