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Mansfield Nursing & Rehabilitation Center

For profit - Corporation  ·  1402 E Broad St, Mansfield, TX 76063  ·  See home’s Medicare page

Special Focus Facility Candidate
Has a history of serious quality issues but has not been formally flagged by the government.
Affiliated With Senior Living Properties
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
3.10
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.3
 
Nurse turnover
Data unavailable
127
Certified beds
Qualifying beds in the certified provider or supplier facility.
68
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Hamilton County Hospital District (100%)
Indirect owners
No indirect owner information
Managerial control
Slp Mansfield Llc since Feb, 2021
Richard Jorgensen since Aug, 2022
Managing employee(s)
Weena Merrill since Feb, 2021

Inspection Reports

39

total deficiencies

2

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Aug 31, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 16, 2023
Complaint report
3 deficiencies
D

to E
E

Resident Rights Deficiency — F0584
Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jul 14, 2023
Complaint report
1 deficiency
$53,552 Fine
H

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
Actual harm that is not immediate jeopardy
Scope
Some people affected
Seriousness
H

Jun 17, 2023
Complaint report
4 deficiencies
$14,528 Fine
J

to K
K

Resident Rights Deficiency — F0580
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
K

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
K

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
K

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Apr 18, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0687
Failure to: Provide appropriate foot care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Feb 23, 2023
Standard report
8 deficiencies
$13,397 Fine
D

to J
J

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Resident Rights Deficiency — F0584
Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0804
Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Quality of Life and Care Deficiency — F0693
Failure to: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0695
Failure to: Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 2, 2023
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Dec 6, 2022
Complaint report
1 deficiency
E

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Nov 8, 2022
Complaint report
5 deficiencies
D

to E
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0552
Failure to: Ensure that residents are fully informed and understand their health status, care and treatments.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0758
Failure to: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0770
Failure to: Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 30, 2022
Complaint report
2 deficiencies
E

Quality of Life and Care Deficiency — F0677
Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Jul 26, 2022
Complaint report
2 deficiencies
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0806
Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

May 9, 2022
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 5, 2022
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0693
Failure to: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nov 16, 2021
Standard report
3 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

$3,250 Fine
D

Pharmacy Service Deficiency — F0759
Failure to: Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Aug 27, 2021
Complaint report
1 deficiency
$20,650 Fine
J

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

May 18, 2021
Complaint report
1 deficiency
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 18, 2021
Complaint report
1 deficiency
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nov 19, 2019
Standard report
2 deficiencies
E

to F
F

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Environmental Deficiency — F0921
Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Penalties

$105K

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Jul 14, 2023
Jun 17, 2023
Feb 23, 2023
Nov 16, 2021
Aug 27, 2021