Mansfield Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mansfield Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 4, 2025

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers, the facility failed to ensure two (2) staff members were present during a mechanical lift transfer resulting in the resident tipping in the lift, hitting his/her head and sustaining an injury. The findings include:Resident #1's diagnoses included severe dementia with agitation, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) affecting the left non-dominant side, muscle weakness and need for assistance with personal care. […]

• Actual harm, isolatedF689Apr 10, 2025

  Based on review of clinical records, review of facility documentation, review of facility policy, and interviews, for two of six sampled residents (Residents #13 and #47) reviewed for accidents, the facility failed to ensure the required staff assistance was utilized during the use of the mechanical lift, and for one of six sampled residents (Resident #33) the facility failed to ensure the required staff assistance was in place during a mechanical lift transfer and failed to ensure the resident was attached to the lift correctly, which resulted in an accident and injury. The findings include: 1. […]

• Actual harm, isolatedF689Apr 11, 2023

  Based on clinical record reviews, facility documentation, facility policy, and interviews for one (2) of six (6) residents reviewed for (Resident #204), the facility failed to ensure a resident had appropriate supervision while in the bathroom, and that leg rests were removed from the wheelchair prior to a transfer, resulting in an injury and for accidents for (Resident # 31), the facility failed to ensure staff remove the plastic covering from a hot beverage within accordance to facility practice to prevent a burn and . The findings included : 1. Resident #204 had diagnoses that included Alzheimer's disease, and weakness of right dominant side following a stroke. […]

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observation, review of facility policy/procedures and interviews, the facility failed to ensure that food stored in the refrigerator and freezer was labeled with an expiration and open date, and the staff failed to wear beard restraints. The findings include: During the initial brief tour of the kitchen on 4/2/25 at 9:41 AM with the Dietary Manager identified cooler #2 contained eight waffles in an open package stored with no expiration date and no open date as well as a Starbucks mocha drink that was 2/3 full. Interview on 4/2/25 at 9:42 AM with the Dietary Manager identified the waffles should be labeled with the open date and the expiration date. […]

• No harm, potential for more than minimal, widespreadF880Apr 10, 2025

  Based on observation, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 residents (Resident #57) reviewed for pressure injuries, the facility failed to ensure facility staff used appropriate PPE when providing care to a resident on Enhanced Barrier Precautions (EBP) and failed to ensure infection control surveillance data collection reports were complete and compiled on a monthly basis. The findings include: 1. Review of the infection control program for the period of April 2023 to January 2024 with the Regional Director of Clinical Operations (RN #7) and the Infection Preventionist (IP) Nurse (RN #4) on 4/7/25 at 12:57 PM failed to identify that monthly surveillance infection reports and analysis of infection trends were completed from April… […]