Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mansfield Nursing Center during CMS and state inspections, most recent first.
A resident's funds were misappropriated by a CNA who transferred money from the resident's bank account to her own without consent. The resident, who was cognitively intact, reported the incident after discovering the missing funds. An internal investigation confirmed the unauthorized transfer, and the facility reported the incident to the police.
The facility did not post the most recent survey results in a location accessible to residents, family, or others. Observations and an interview with the administrator confirmed the absence of the survey results in an easily accessible place.
The facility failed to ensure proper use and documentation for bed rails for four residents, lacking necessary assessments, physician orders, and informed consents. Residents with significant mobility and cognitive impairments were observed with bed rails installed without required documentation, as confirmed by staff interviews.
The facility failed to monitor two residents for side effects from antidepressant and antianxiety medications. One resident was not monitored for side effects from an antidepressant, despite having a care plan requiring such monitoring. Another resident, with multiple diagnoses and prescribed several medications, was also not monitored for side effects. The Director of Nursing acknowledged these oversights.
A facility failed to monitor a resident for edema while the resident was on a diuretic medication. The resident, with heart failure and diabetes, was prescribed Chlorthalidone. However, the medication administration record showed no monitoring for edema, which was acknowledged by the DON.
Misappropriation of Resident Funds by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and exploitation by staff. A Certified Nursing Assistant (CNA) transferred money from the resident's bank account to her personal account without the resident's consent. The resident, who was cognitively intact, reported the incident to the facility administrator after discovering the missing funds during a bank visit with her aunt. The facility's internal investigation revealed that the CNA's mother, who also worked at the facility, facilitated the transaction by offering her daughter's account for the transfer. The resident denied requesting the use of the CNA's account for any financial transactions. The facility administrator confirmed the unauthorized transfer of $250 to the CNA's account and reported the incident to the police. The facility's abuse prevention policy clearly states that residents should be free from exploitation and misappropriation of property. Despite this policy, the staff involved acted against the resident's rights, leading to the deficiency. The facility's administrator took immediate action by suspending the involved staff and initiating an investigation, but the money was not recovered at the time of the report.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location that was readily accessible to residents, family members, or anyone wishing to review them. On the morning of August 12, 2024, observations were made that did not reveal the presence of the most recent survey results in an accessible location. This was further confirmed during an observation with the facility's administrator, who acknowledged that the survey results were not posted in a place that was easily available for review. During an interview later that morning, the administrator confirmed that the survey results should have been posted for residents, family, and others to review.
Failure to Ensure Proper Use and Documentation for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for four residents, as evidenced by the lack of necessary assessments, physician orders, and informed consents. Resident #8, who has functional quadriplegia and a history of falling, was observed with bed rails in place without a physician's order, risk assessment, or signed consent. Interviews with staff confirmed the absence of these critical documents. Similarly, Resident #10, with severely impaired cognition and total dependence for transfers, was found to have bed rails installed without the required physician's order, risk assessment, or consent. Observations confirmed the presence of bed rails, and staff interviews corroborated the lack of documentation. Resident #13 and Resident #37 also had bed rails installed without physician orders or consents. Both residents have significant mobility and cognitive impairments, requiring assistance for bed mobility and transfers. Observations and staff interviews confirmed the use of bed rails and the absence of necessary documentation, highlighting a systemic issue in the facility's management of bed rail safety protocols.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free of unnecessary medications, specifically for two residents out of five reviewed. Resident #13 was not monitored for side effects while receiving an antidepressant medication, despite having a comprehensive care plan that required assessment for adverse reactions and documentation of side effects. The resident's August 2024 Medication Administration Record did not show any monitoring for side effects, which was acknowledged by the Director of Nursing during an interview. Similarly, Resident #39 was not monitored for side effects from both antidepressant and antianxiety medications. The resident had multiple diagnoses, including cognitive communication deficit, generalized anxiety disorder, and major depressive disorder, and was prescribed several medications, including Lorazepam, Duloxetine, Buspirone, and Divalproex Sodium. However, the August 2024 Medication Administration Record did not reveal any monitoring for side effects, which was also acknowledged by the Director of Nursing.
Failure to Monitor Resident for Edema While on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not monitor a resident for edema while the resident was receiving a diuretic medication. The resident, who was admitted with diagnoses including heart failure and type 2 diabetes mellitus with diabetic neuropathy, had a physician's order for Chlorthalidone, a diuretic, to be administered daily. However, a review of the resident's medication administration record for August 2024 showed no evidence of monitoring for edema. During an interview, the Director of Nursing acknowledged that the resident was not monitored for edema as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desoto Retirement & Rehab Ctr, Llc | 1.6 mi | — | 2 | 0 |
| Green Meadow Haven | 20.2 mi | — | 0 | 0 |
| Village Health Care At The Glen | 24.9 mi | — | 3 | 0 |
| Heritage Manor South | 25 mi | — | 4 | 0 |
| Live Oak | 25 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.