Liberty Nursing Center of Mansfield

In the surveyor’s words

From the most serious findings on record at Liberty Nursing Center of Mansfield, in the surveyor’s own words.

• Actual harm, isolatedF684May 13, 2025

  Based on resident representative interview, staff interview, medical record review, hospital record review, and review of facility policy, the facility failed to ensure the facility bowel protocol was implemented timely for residents who have not had bowel movements and failed to ensure residents received timely intervention for constipation. This resulted in Actual Harm when Resident #45 had no recorded bowel movement for five days, experienced abdominal pain, and had episodes of emesis with a fecal odor. Resident #45 was transferred to a local hospital and admitted for treatment for dehydration and constipation. Additionally, the facility failed to timely implement their bowel protocol, placing Resident #18 at risk for the potential for more than minimal harm that was not Actual Harm. […]

• Actual harm, isolatedF686Sep 7, 2022

  Based on medical record review, observation, interview, and review of the National Pressure Injury Advisory Panel (NPIAP) staging, the facility failed to ensure early identification and ensure treatments of skin injuries were completed. This resulted in Actual Harm when Resident #50 acquired a pressure ulcer to the coccyx and the wound was not assessed or treated until the wound progressed into a stage three pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia). This affected one resident (#50) out of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2025

  Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 57 residents who received food from the kitchen. The facility identified one resident (#313) as receiving nothing by mouth. The facility census was 58. Findings include: Observation on 05/05/25 beginning at approximately 8:15 A.M. of the dishwashing area located in the kitchen revealed there was a pipe which ran along the lower part of the wall, near the floor. There was a black, white, and grey substance built up along the lower part of the wall and a dark puddle of water in the corner on the floor where the walls met. There was also a rubber mat in the dishwashing area which had circular holes for draining. […]

• No harm, potential for more than minimal, widespreadF887May 13, 2025

  Based on review of an all-staff roster, review of staff COVID-19 declination forms, staff interview, and policy review, the facility failed to ensure all staff received education and vaccine information sheets regarding the COVID-19 vaccine. This affected 54 of 79 staff and had the potential to affect all residents. The facility census was 58. Findings include: Review of the all-staff roster provided by the facility revealed there were 79 staff currently employed by the facility. Review of facility documentation revealed no documentation 54 staff had been offered the annual COVID-19 vaccine and received education regarding the risks and benefits of the annual COVID-19 vaccine. […]

• No harm, potential for more than minimal, patternF605May 13, 2025

  5. Review of the medical record for Resident #45 revealed an admission date of 12/21/22 with a diagnoses of Parkinson's disease, peripheral vascular disease, and dementia. Review of the MDS quarterly assessment dated [DATE] revealed Resident #45 was severely cognitively impaired. Review of Resident #45's physician orders dated 06/01/23 revealed an order for Citalopram 20 mg daily for depression and an order dated 02/11/25 for trazodone HCL (an antidepressant) 150 mg, one half tablet by mouth at bedtime related to adjustment disorder with mixed anxiety and depressed mood. Review of Resident #45's care plan revised 05/05/25 revealed the resident used psychotropic medications related to behavior management. Interventions included monitoring side effects and effectiveness every shift. […]