Inspection Reports for
Mansfield Nursing Center
1725 MCARTHUR DRIVE, MANSFIELD, LA, 71052
Back to Facility Profile6 Reports
Inspection Report — Aug 13, 2025
Routine CMS
Date: Aug 13, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, transfer/discharge procedures, respiratory care, pharmaceutical services, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for assist rails, failure to provide required written notices and ombudsman notifications for transfers/discharges, inadequate respiratory care practices, inaccurate controlled drug record maintenance, and insufficient infection control measures including lack of enhanced barrier precautions for certain residents.
Deficiencies (5)
Failed to accommodate the needs of a resident by not reassessing for use of assist rails.
Failed to provide written notice of transfer/discharge and notify the State's Long Term Care Ombudsman in writing for discharged/transferred residents.
Failed to ensure respiratory care was provided consistent with professional standards and facility policies, including failure to change oxygen tubing weekly, improper storage of respiratory mask, and lack of oxygen in use signage.
Failed to maintain and reconcile the Controlled Drug Record accurately for medication cart reviewed.
Failed to implement infection prevention and control program adequately, including lack of enhanced barrier precaution signage, PPE availability, and orders for residents requiring such precautions.
Report Facts
Residents reviewed for transfer/discharge: 2
Residents reviewed for respiratory care: 2
Residents requiring enhanced barrier precautions: 3
Remaining doses discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 CNA | Certified Nursing Assistant | Reported Resident #8 used bed rails to turn and aid in mobility and requested bed rails to be replaced. |
| S4 LPN | Licensed Practical Nurse | Reported Resident #8 used bed rails for turning assistance and confirmed oxygen tubing change policy and medication record discrepancy. |
| S6 LPN/MDS nurse | Licensed Practical Nurse / MDS Nurse | Reported bed rail assessment should be completed quarterly or upon status changes. |
| S7 LPN/MDS | Licensed Practical Nurse / MDS Nurse | Reported residents have the right to have assist rails. |
| S2 DON | Director of Nursing | Reported nursing does not provide written notice of bed hold at discharge/transfer and confirmed narcotics documentation requirements. |
| S3 Social Services | Social Services | Reported written notice of bed hold not provided and confirmed ombudsman notification not done. |
| S1 Administrator | Administrator | Confirmed State's Long-Term Care Ombudsman had not been notified of certain transfers/discharges. |
| S4 LPN | Licensed Practical Nurse | Reported oxygen tubing was not changed weekly as required and acknowledged medication record discrepancy. |
| S9 LPN | Licensed Practical Nurse | Confirmed nebulizer masks should be stored in plastic bags and verified lack of enhanced barrier precautions. |
| S10 CNA | Certified Nurse Aid | Observed providing care using gloves only and confirmed lack of enhanced barrier precautions. |
| S11 Student CNA | Student Certified Nurse Aid | Observed providing care using gloves only. |
| S13 Infection Control | Infection Control | Verified lack of enhanced barrier precaution signage, PPE availability, and orders for residents requiring precautions. |
| S14 CNA | Certified Nurse Aid | Reported lack of signage and PPE for residents on precautions. |
| S12 PTA | Physical Therapy Assistant | Confirmed no signage for resident #79 and lack of awareness of enhanced barrier precautions. |
Inspection Report — Mar 19, 2025
Complaint Investigation CMS
Date: Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint alleging misappropriation of property and exploitation by staff involving a Certified Nursing Assistant transferring money from a resident's bank account to her personal account.
Complaint Details
The complaint investigation substantiated that S2 CNA transferred $250 from Resident #1's bank account to her personal account without consent. Resident #1 was cognitively intact and denied authorizing the transfer. The facility suspended and terminated the involved CNAs and notified police. The money was never recovered and the facility planned to reimburse the resident if police investigation yielded no outcome.
Findings
The facility failed to protect a resident from financial exploitation by staff. A CNA transferred $250 from Resident #1's bank account to her own without consent. The facility conducted an internal investigation, suspended and terminated the involved CNAs, notified police, and implemented corrective actions including staff training and resident safety audits.
Deficiencies (1)
Failed to protect resident from abuse including misappropriation of property and exploitation by staff transferring money from resident's bank account to personal account.
Report Facts
Amount transferred: 250
Dates of abuse/safety questionnaires: 5
Residents interviewed weekly for monitoring: 8
Monitoring duration: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 CNA | Certified Nursing Assistant | Transferred money from Resident #1's bank account to her personal account; suspended and terminated |
| S3 CNA | Certified Nursing Assistant | Mother of S2 CNA; involved in handling money; suspended and terminated |
| S1 Administrator | Administrator | Reported the abuse, conducted investigation, suspended staff, notified police, and implemented corrective actions |
Inspection Report — Aug 14, 2024
Routine CMS
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including posting of survey results, proper use and consent for bed rails, and ensuring residents' drug regimens are free from unnecessary medications.
Findings
The facility failed to post the most recent survey results in a place accessible to residents and family. It also failed to ensure proper assessment, physician orders, and consent for bed rails for multiple residents. Additionally, the facility did not monitor certain residents for side effects and edema related to their medications.
Deficiencies (4)
Failed to post the most recent survey results in a place readily accessible to residents, family members, or anyone to review.
Failed to ensure correct use and maintenance of bed rails by assessing risk, obtaining physician orders, and informed consent for 4 out of 7 residents reviewed.
Failed to ensure each resident's drug regimen was free from unnecessary drugs; specifically failed to monitor Resident #39 for edema while receiving a diuretic.
Failed to implement gradual dose reductions and monitor side effects for psychotropic medications for Residents #13 and #39.
Report Facts
Residents reviewed for bed rails: 7
Residents with bed rail deficiencies: 4
Residents reviewed for unnecessary medications: 5
Residents with drug regimen deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Confirmed survey results were not posted in a place readily available for review. | |
| S2 Director of Nursing | Acknowledged lack of assessment, physician orders, and consent for bed rails; acknowledged failure to monitor residents for edema and side effects. | |
| S3 Licensed Practical Nurse | Confirmed Residents #8 and #10 had bed rails in use. | |
| S4 Certified Nursing Assistant | Confirmed Residents #8 and #10 had bed rails in use. |
Inspection Report — Sep 28, 2023
Complaint Investigation CMS
Date: Sep 28, 2023
Visit Reason
The inspection was conducted following complaints regarding undignified treatment of residents by the Activities Director and concerns about medication administration and accommodation of resident needs.
Complaint Details
The complaint investigation was triggered by reports from residents about the Activities Director scolding residents in an undignified manner, causing emotional distress. Interviews with residents and staff confirmed the behavior and subsequent suspension of the Activities Director.
Findings
The facility failed to ensure residents were treated with dignity and respect, with the Activities Director reprimanding residents causing emotional distress. Additionally, the facility failed to accommodate a resident's needs related to mobility and call light access, and failed to administer medications as ordered, resulting in a medication error rate of 14.81%.
Deficiencies (4)
Residents were treated without dignity and respect by the Activities Director, causing emotional distress.
Failed to reasonably accommodate the needs and preferences of a resident who could not reach call light or personal items due to wheelchair placement.
Failed to provide appropriate treatment and care according to physician orders by administering incorrect medication dosages to a resident.
Failed to maintain medication error rates below 5%, with 4 medication errors observed among 7 residents during medication administration.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents observed: 7
Medication error opportunities: 27
Medication errors: 4
Medication error rate: 14.81
BIMS scores: 14
BIMS scores: 15
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7 Activities Director | Activities Director | Named in findings related to undignified treatment of residents and subsequent suspension |
| S1 Administrator | Administrator | Confirmed undignified behavior of Activities Director |
| S2 Director of Nursing | Director of Nursing | Confirmed undignified behavior of Activities Director and medication errors |
| S3 Corporate Nurse | Corporate Nurse | Confirmed undignified behavior of Activities Director |
| S4 LPN | Licensed Practical Nurse | Observed medication administration and reported medication unavailability |
| S5 LPN | Licensed Practical Nurse | Observed medication administration and reported oversight in medication administration |
| S6 CNA | Certified Nurse Assistant | Reported on resident #52's bed assignment and call light placement |
Inspection Report — Jul 13, 2023
Annual Inspection CMS
Date: Jul 13, 2023
Visit Reason
Annual survey inspection of Mansfield Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Mar 21, 2023
Annual Inspection CMS
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards and the comprehensive person-centered plan of care, specifically focusing on restorative services provided to residents.
Findings
The facility failed to provide restorative services according to Resident #1's comprehensive plan of care. Resident #1 was not receiving restorative services as ordered, and was omitted from the list of residents receiving such services despite physician orders and therapy recommendations.
Deficiencies (1)
Failure to provide restorative services according to Resident #1's comprehensive plan of care.
Report Facts
Deficiencies cited: 1
Resident admission date: Sep 27, 2022
Restorative exercise duration: 15
Restorative exercise frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Restorative Aide | Reported Resident #1 was not receiving restorative services | |
| S2 Physical Therapist | Reported Resident #1 should have been receiving restorative therapy | |
| S1 Medicaid/Restorative LPN | Responsible for resident restorative services; confirmed Resident #1 was not receiving restorative services |
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