Nursing and Rehabilitation at the Mansion

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 19, 2024

  Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions and provide adequate supervision to prevent a fall for one of three residents reviewed for falls that resulted in harm (Resident 5). This deficiency is cited as past non-compliance. Findings include: Clinical record review revealed the facility admitted Resident 5 on March 26, 2015. Review of Resident 5's plan of care initiated on March 26, 2015, indicated that Resident 5 is at risk for falls related to her diagnosis of Alzheimer's dementia, history of falls, syncope, and noncompliance with assistance with transfers. […]

• No harm, potential for more than minimal, patternF812Dec 19, 2025

  Based on observation and staff interview, it was determined that the facility failed to prepare and store food items in a safe and sanitary manner in the facility's main kitchen.Findings included: Observation of the facility's main kitchen on December 16, 2025, at 8:00 AM revealed the following: There was an accumulation of dust on the stainless-steel hood over the stove. The dry goods storage area contained a white colored heating/cooling unit on the wall near the ceiling. The unit had a build-up of a blackish colored substance on the vents of the unit. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 17, 2025, at 2:00 PM. […]

• No harm, potential for more than minimal, patternF848Dec 19, 2025

  Based on a review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 13 and 50).Findings include: Review of an Addendum XIII: Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial), signed by Resident 13's responsible party on March 20, 2025, revealed that the document stipulated that, By signing this Arbitration Agreement, the parties hereby agree that if the parties cannot agree on a neutral… […]

• No harm, potential for more than minimal, patternF695Nov 15, 2024

  Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for three of three residents reviewed for supplemental oxygen concerns (Residents 4, 5, and 15). Findings include: Clinical record review for Resident 4 revealed an active physician's order dated November 29, 2023, for staff to apply supplemental oxygen at two liters per minute (lpm) continuously every shift for shortness of breath. Observation of Resident 4 on November 12, 2024, at 11:01 AM, and November 13, 2024, at 10:03 AM, revealed Resident 4 was in bed with oxygen on and running at three lpm. […]

• No harm, potential for more than minimal, patternF726Nov 15, 2024

  Based on review of select facility policies and procedures, clinical record review, observation, resident and staff interview, and review of personnel records, it was determined that the facility failed to ensure specific competencies necessary to care for resident needs for one of one resident reviewed for intravenous access concerns (Resident 163; Employees 5, 7, 8, 9, 10, and 11). Findings include: The facility policy entitled, Infusion Therapy Responsibilities and Scope of Practice, last reviewed without changes on January 3, 2024, revealed that clinicians administering infusion therapies will practice within the scope of practice for their licensure and applicable state laws, and within their clinical level of competency as established by the facility training and competency… […]