Inspection Report
Re-Inspection
Deficiencies: 0
Aug 28, 2025
Visit Reason
A revisit survey was conducted on August 28, 2025, to verify correction of all previous deficiencies cited on July 15, 2025, during the Life Safety Code survey. Additionally, an off-site desk audit was conducted on September 2, 2025, for the Recertification survey to verify correction of deficiencies cited on July 18, 2025.
Findings
All deficiencies from the prior surveys have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 52
Capacity: 62
Deficiencies: 7
Jul 18, 2025
Visit Reason
A recertification and complaint surveys were conducted from 7/15/2025 through 7/18/2025 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to notification of personal funds upon resident death, behavioral health services, drug regimen review, unnecessary drugs, quality assurance and performance improvement, nursing service and minimum staffing, and life safety code compliance. The facility was found not in compliance with all regulations surveyed.
Severity Breakdown
B: 1
D: 2
E: 1
F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to notify each resident or representative receiving Medicaid benefits upon death with personal funds deposited, within 30 days, and provide final accounting. | B |
| Facility failed to provide necessary behavioral health care and services for a resident with mental disorder and trauma history. | D |
| Facility failed to ensure drug regimen reviews by pharmacist were acted upon for 4 of 4 residents reviewed. | E |
| Facility failed to ensure resident drug regimen was free from unnecessary drugs for 1 resident reviewed. | D |
| Facility failed to establish and implement effective Quality Assurance and Performance Improvement (QAPI) program. | F |
| Facility failed to provide 24-hour registered nurse coverage on multiple dates. | — |
| Facility failed to comply with Life Safety Code requirements including building construction type, aisle width, number of exits, electrical systems, and emergency power supply. | F |
Report Facts
Facility census: 52
Facility capacity: 62
Dates of survey: 4
Residents reviewed for drug regimen irregularities: 4
Residents reviewed for unnecessary drugs: 1
Dates RN coverage missing: 11
Residents potentially impacted by Life Safety deficiencies: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding psychiatric medication recommendations and RN coverage |
| Registered Nurse Staff A | Registered Nurse | Interviewed regarding psychiatric recommendations and medication administration |
| Director of Operations | Director of Operations | Interviewed regarding life safety tour and electrical equipment issues |
| Administrator | Administrator | Interviewed regarding RN coverage and QAPI program |
| Director of Nursing Hours | Director of Nursing Hours | Mentioned in staffing requirements section |
Inspection Report
Plan of Correction
Census: 52
Capacity: 62
Deficiencies: 8
Jul 18, 2025
Visit Reason
A recertification and complaint survey was conducted to determine compliance with 42 CFR, Part 483, requirements for Long Term Care Facilities, State licensure, and emergency preparedness surveys.
Findings
Deficiencies were identified related to the notice and conveyance of personal funds, behavioral health services, drug regimen review, nursing service and minimum staffing, life safety code compliance, and emergency preparedness. Plans of correction were submitted addressing each deficiency with specific corrective actions and timelines.
Severity Breakdown
Level B: 1
Level D: 3
Level E: 1
Level F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to notify each resident or representative about Medicaid benefits upon death with personal funds held by the facility. | Level B |
| Facility failed to provide necessary behavioral health care and services for a resident with mental disorder and trauma history. | Level D |
| Facility failed to ensure drug regimen review was conducted monthly and irregularities addressed for multiple residents. | Level E |
| Facility failed to ensure drug regimen was free from unnecessary drugs for a resident. | Level D |
| Facility failed to ensure medication administration was accurate and within prescribed parameters for a resident. | Level D |
| Facility failed to establish and implement effective QAPI program to monitor and improve quality of care. | Level F |
| Facility failed to maintain minimum staffing with registered nurses on premises 24 hours a day. | Level F |
| Facility failed to comply with life safety code requirements including building construction type, corridor width, exits, electrical systems, and emergency power supply. | Level F |
Report Facts
Facility census: 52
Facility capacity: 62
Dates of survey: Survey conducted from 07/15/2025 through 07/18/2025
Completion date for POC: Plan of Correction completion date August 17, 2025
Number of deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Telysa Chapman | Administrator | Signed the Plan of Correction and involved in findings related to personal funds and staffing |
Inspection Report
Annual Inspection
Census: 55
Capacity: 62
Deficiencies: 12
Jul 5, 2024
Visit Reason
A Recertification Survey, complaint investigation survey, and emergency preparedness survey were conducted at Mansion Nursing and Rehab Center from 7/1/2024 through 7/5/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities and state licensure.
Findings
Multiple deficiencies were cited related to protection/management of personal funds, accounting and records, privacy and confidentiality, comprehensive care plans, respiratory care, medication storage, food safety, infection prevention and control, life safety code violations, and nursing service staffing. Plans of correction were provided for each deficiency with corrective actions and monitoring plans.
Severity Breakdown
Level B: 5
Level E: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to obtain written authorization to hold residents' personal funds for 2 of 6 residents reviewed. | Level B |
| Facility failed to ensure residents were given a written accounting of deposits, withdrawals, and balances at least quarterly for 2 of 6 residents reviewed. | Level B |
| Facility failed to notify residents when their accounts reached $200 less than the SSI resource limit for 3 of 6 residents reviewed. | Level B |
| Facility failed to ensure services met professional standards of practice for 1 of 1 resident reviewed related to lab testing. | Level B |
| Facility failed to provide respiratory care consistent with professional standards for 1 of 2 residents reviewed. | Level B |
| Facility failed to store medications properly; medication storage room contained expired medications and improperly dated medications. | Level E |
| Facility failed to prepare, store, and distribute food according to professional standards; ice machine and kitchenette had sanitation issues. | Level E |
| Facility failed to maintain an infection prevention and control program to prevent development and transmission of infections; water management and enhanced barrier precautions deficiencies noted. | Level E |
| Facility failed to maintain privacy and confidentiality of residents' personal and medical records related to posting of resident names on survey rosters. | Level B |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment; environmental repairs and maintenance issues noted. | Level E |
| Facility failed to maintain adequate nursing service staffing to provide 24-hour registered nurse coverage for 28 of 38 days reviewed. | Level E |
| Facility failed to maintain life safety code compliance related to building construction, egress doors, sprinkler system installation, and fire alarm system. | — |
Report Facts
Residents reviewed for personal funds authorization: 6
Residents reviewed for quarterly accounting: 6
Residents reviewed for SSI notification: 6
Resident census: 55
Facility capacity: 62
Days without 24-hour RN coverage: 28
Medication storage observations: 31
Medication storage observations: 6
Ice machine observations: 1
Fire safety evaluation system score: passing
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Chipman | Administrator | Named in relation to plan of correction and interviews |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 30, 2023
Visit Reason
An off-site desk audit was conducted on August 30, 2023, to review all previous deficiencies cited on July 19 and July 21, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, the deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 10
Jul 21, 2023
Visit Reason
The annual Federal Life Safety Code survey and recertification and complaint investigation survey were conducted at Mansion Nursing and Rehab Center to assess compliance with federal and state regulations including long term care facility requirements and life safety codes.
Findings
Multiple deficiencies were cited related to comprehensive care plans, physician supervision, food safety, facility assessment, resident rights, abuse prevention training, and fire safety compliance. The facility failed to meet professional standards in care planning, documentation, medication administration, food handling, and fire drill requirements.
Complaint Details
The survey included an off-hour recertification and complaint investigation survey conducted from 7/18/2023 through 7/21/2023 to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Deficiencies (10)
| Description |
|---|
| Failure to meet professional standards of quality in comprehensive care plans for residents. |
| Failure to ensure medical care of residents was supervised by a physician. |
| Failure to properly store, prepare, distribute, and serve food in accordance with professional standards. |
| Failure to conduct and document a facility-wide assessment to determine resources necessary to care for residents. |
| Failure to maintain medical records accurately and completely for residents. |
| Failure to provide education and training on resident rights to all staff. |
| Failure to provide training on abuse, neglect, and exploitation to all staff. |
| Failure to conduct fire drills as required on all shifts and maintain fire drill documentation. |
| Failure to achieve a passing score on the Fire Safety Evaluation System (FSES) due to non-compliance with fire drill requirements. |
| Failure to maintain a registered nurse on premises 24 hours a day for 24 of 105 shifts reviewed. |
Report Facts
Residents reviewed for care plan compliance: 13
Residents reviewed for physician supervision: 2
Staff reviewed for abuse training: 15
Shifts reviewed for RN coverage: 105
Fire drills required: 52
Fire drills not conducted: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Chapman | Administrator | Signed the Plan of Correction and was interviewed regarding facility assessments and fire drill compliance. |
| Staff A | Certified Nursing Assistant | Observed during meal intake and interviewed regarding documentation of dietary supplements. |
| Staff C | Registered Nurse | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff D | Licensed Practical Nurse | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff E | Certified Nursing Assistant | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff F | Cook | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff G | Dietary Aide | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff H | Laundry | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
| Staff I | Maintenance | Identified as staff who failed to receive abuse, neglect, and exploitation training. |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 13, 2022
Visit Reason
A follow-up to a previous life safety survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 27, 2022
Visit Reason
The document is a review of the Plan of Correction submitted by Mansion Nursing and Rehab Center following a survey completed on June 16, 2022, to determine if on-site follow-up is necessary.
Findings
Based on an off-site desk audit conducted on July 27, 2022, all previously cited deficiencies from the June 16, 2022 survey have been corrected, and the facility is in substantial compliance with all regulations.
Report Facts
Date of original survey: Jun 16, 2022
Date of desk audit: Jul 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Olsen-Armstrong | Chief, Center for Health Facilities Regulation | Signed letter regarding Plan of Correction review |
| Matthew Raymond | Facilities Regulation | Contact person for questions concerning the letter |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 62
Deficiencies: 9
Jun 15, 2022
Visit Reason
A Recertification Survey was conducted from 6/13/2022 through 6/16/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey, a vaccination compliance survey, and a complaint survey (ACTS reference number 85399).
Findings
Deficiencies were identified related to comprehensive assessments and timing, qualifications of activity professional, drug regimen free from unnecessary drugs, medication errors, dental services, food in form to meet individual needs, food procurement and safety, and life safety code violations. Plans of correction were submitted for each deficiency with specific corrective actions and timelines.
Complaint Details
The survey included a complaint investigation referenced by ACTS number 85399.
Severity Breakdown
SS=E: 4
SS=C: 1
SS=D: 3
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Comprehensive Assessments & Timing - Facility failed to conduct comprehensive assessments using the resident assessment instrument (RAI) for multiple residents, with assessments overdue by days to weeks. | SS=E |
| Qualifications of Activity Professional - Facility failed to provide an activities program directed by a qualified professional; no activities director employed. | SS=C |
| Drug Regimen is Free from Unnecessary Drugs - Facility failed to ensure residents' drug regimens were free from unnecessary drugs, including excessive dosing and lack of adequate monitoring. | SS=D |
| Free of Medication Error Rates 5 Percent or More - Facility failed to ensure medication error rates were below 5%, with errors observed in medication administration. | SS=E |
| Label/Store Drugs and Biologicals - Facility failed to properly label and store drugs and biologicals, including expired or undated medications. | SS=E |
| Routine/Emergency Dental Services in Skilled Nursing Facilities - Facility failed to assist residents in obtaining routine and emergency dental care. | SS=D |
| Food in Form to Meet Individual Needs - Facility failed to ensure residents received food in the appropriate form for their needs. | SS=D |
| Food Procurement/Store/Prepare/Serve-Sanitary - Facility failed to properly store, distribute, and serve food under sanitary conditions, including temperature monitoring and cleanliness. | SS=F |
| Life Safety Code Deficiencies - Facility failed to achieve a passing score on the Fire Safety Evaluation System, with issues related to building construction, number of exits, and fire escape accessibility. | SS=F |
Report Facts
Census: 54
Total Capacity: 62
Days Overdue: 68
Days Overdue: 1
Days Overdue: 21
Days Overdue: 14
Days Overdue: 7
Days Overdue: 39
Medication Error Rate: 5.71
Number of Deficiencies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Chipman | Administrator | Signed the statement of deficiencies and plan of correction |
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