Inspection Reports for Mansfield Medical Lodge

The complaint investigation revealed failures in care planning and wound care for two residents, including missing wound care documentation, improper wound dressing management, and inadequate use of pressure-relieving devices. The previous wound care nurse was found to have documentation issues leading to incomplete wound care records. Weekend care was noted to be less consistent, with charge nurses covering wound care responsibilities in the absence of a dedicated wound care nurse.

The facility failed to develop and implement complete care plans addressing residents' needs, including measurable objectives and timeframes, specifically for wounds and pacemaker care. Additionally, the facility failed to provide necessary wound care and pressure ulcer treatment, including failure to follow physician orders, maintain functioning low air loss mattresses, and properly document wound care treatments, placing residents at risk of inadequate care and worsening pressure ulcers.

The complaint investigation focused on Resident #1's abrupt discharge without proper Medicaid application submission and failure to notify the Ombudsman of discharges. The family expressed concerns about lack of assistance with Medicaid application and inadequate notification. The facility staff and administration provided conflicting statements about Medicaid application submission responsibilities and notification procedures. The Ombudsman confirmed lack of notification since July 2024.

The facility failed to submit Resident #1's Medicaid application despite family interest, resulting in an abrupt discharge. The facility also failed to notify the Ombudsman timely about Resident #1's discharge and other discharges in August 2024. Interviews revealed inconsistent practices and lack of proper documentation and notification procedures.

The facility failed to discard expired glucometer control solution from the 200 hall medication cart, which placed residents at risk of inaccurate glucose readings due to ineffective calibration. Interviews with nursing staff and review of policies confirmed the failure to check expiration dates and ensure proper calibration procedures.

The facility failed to provide proper pharmaceutical services by not discarding expired glucometer control solutions on one medication cart, risking inaccurate glucose readings. Additionally, the kitchen failed to properly store food, with moldy produce, exposed and unsealed food items, and unsanitary conditions, posing a risk for food-borne illness.

The facility failed to ensure appropriate care and removal of an unused feeding tube for Resident #14, failed to follow proper medication administration procedures via g-tube for Resident #71, and failed to ensure expired medications and unlabeled insulin were properly removed and labeled on multiple medication carts and the facility refrigerator.

The complaint investigation revealed substantiated failures related to notification of physician and dietitian about a resident's feeding intolerance, resulting in aspiration pneumonia and hospitalization. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to notify Resident #52's physician and dietitian when she was not tolerating her bolus feedings, resulting in aspiration pneumonia and hospitalization. An Immediate Jeopardy was identified but removed after the facility implemented a Plan of Removal including staff education and monitoring. The facility also failed to maintain proper infection control practices related to disinfecting blood pressure cuffs between residents.