MANSFIELD PLACE
Non profit - Corporation
60 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#51 of 122 in WV
Photo by Mansfield Place
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Mansfield Place in Philippi, West Virginia, has a Trust Grade of D, indicating below-average quality and some serious concerns. It ranks #51 out of 122 facilities in the state, placing it in the top half, and is the best option in Barbour County. The facility's trend is improving, with issues decreasing from 11 in 2023 to 8 in 2025. Staffing is rated average, with a turnover rate of 50%, which is close to the state average. Although there have been no fines, the facility has faced significant incidents, such as a resident suffering fatal injuries after being struck by a tray cart and failures in timely reporting potential abuse allegations, raising concerns about resident safety.
- Trust Score
- D
- In West Virginia
- #51/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 41%
Review needed
11 → 8 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 11 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 50%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
The Ugly 23 deficiencies on record
1 life-threatening
Jul 2025
8 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews, the facility failed to ensure that each resident received adequate su...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews, the facility failed to ensure that each resident received adequate supervision and was protected from avoidable accident hazards. Specifically, the facility failed to prevent a resident (Resident #58) from being struck by a tray cart pushed by a CNA, which caused the resident to fall, sustain multiple traumatic brain injuries, require emergency medical intervention, and ultimately resulted in the resident's death. Resident identifier: #58 Facility Census:56 This failure placed all residents who ambulate or are present in high-traffic hallways at risk for serious harm, injury, or death due to unsafe transportation of tray carts. Findings Include:Record Review of Incident on [DATE]:On [DATE] at 6:17 PM, Resident #58 was observed via camera footage sitting in a chair at the nurse's station.At 6:22 PM, Resident #58 stood and was facing the dining room with his back to NA #1, who was pushing a tall tray cart.CNA #1 struck Resident #58 in the back with the tray cart, causing him to fall forward onto his left side.RN #3 responded immediately and a rapid response was called at 6:23 PM.The Emergency Department (ED) team and a physician arrived at 6:25 PM. A cervical collar was applied, and Resident #58 was transported to the ED.Observation on [DATE] by Surveyors:The area of the incident was observed to be well-lit, clean, and free of clutter or medical equipment.This hallway is a high-traffic area used by staff, residents, and visitors.The resident's position at the time of the incident, as seen in the video footage, showed that visibility may have been obstructed by the tray cart, which measured 5 feet 5 inches in height.Two surveillance cameras were visible in the area.ED Medical Record Review:Resident #58 was diagnosed with:Acute Extensive Traumatic Subarachnoid Hemorrhage (tSAH) - bleeding into the subarachnoid space following head trauma.Acute Left Frontal Intraparenchymal Hemorrhage - a hemorrhagic stroke due to ruptured blood vessels in the brain tissue.Left Parafalcine Subdural Hematoma - blood collection between the brain and dura mater.Resident #58 was life-flighted as a Priority Two Trauma to another hospital due to the severity of injuries.Facility Progress Notes:Resident was reported as unconscious for ~1 minute post-fall.The facility was notified later that evening (around 9:00 PM) that Resident #58 had been transported via Life Flight.On [DATE], the hospital initiated a palliative care consult, determined the resident's status to be Do Not Resuscitate (DNR), and discussed transitioning to comfort care.Facility's Five-Day Report:Abuse/neglect was not substantiated.NA was not observed acting maliciously or at excessive speed.The tray cart was tall, obstructing forward vision.The facility concluded that the resident was in close proximity when he stood and could not be seen by CNA #1.Corrective Actions Taken:As of [DATE], Assistant Administrator (AA #4) reported the following:A new policy requires two staff members to push tray carts-one pushing, one ensuring the path is clear.If only one staff member is available, they must pull the cart instead of pushing. Director of Nursing (DON) provided education records confirming staff training began immediately and was completed by [DATE].Environmental Changes:Bubble mirrors installed in the hallways on [DATE] and completed on [DATE] to improve visibility.Shorter tray carts are being ordered and utilized in hallways; taller carts are reserved for dining room delivery.This deficient practice resulted in Immediate Jeopardy beginning on [DATE] when the resident was struck by a cart, suffered severe head trauma, and subsequently died. The facility's failure to ensure safe cart handling in a high-traffic resident area placed all residents at risk of serious injury or death. Immediate corrective action was required. This is now considered past-noncompliance / facility self-corrected prior to survey entrance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to follow orders to release Resident #7 from the seat belt every two (2) hours. This was a random opportunity for discovery during the ...
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Based on record review and staff interviews, the facility failed to follow orders to release Resident #7 from the seat belt every two (2) hours. This was a random opportunity for discovery during the Long Term Care Survey. Resident identifier: #7 Facility Census: 56 Findings include:Record review:07/23/2025 10:00 AM Orders placed on 2/3/25Release seatbelt every two hours, reposition, skin checks, proper attachment of seat belt and pericare.Special Instructions: prevent skin breakdown.Every 2 Hours07:00, 09:00, 11:00, 13:00, 15:00, 17:00no documentation showing release belt and checking of resident every two hours as per orderresident #7 unable to self release belts due medical conditions. This is considered a restraint when a patient can not release belt by themselves.Don #102 stated that she would look into the matter and bring me any documentation they find.Interviews:7/23/2025 @1030 Interview with Nurse Aide (NA) and nurse on hall with residentNA #101 stated when he is up we check on him every 2 hours, but CNA's don't have a place to chart it. CNA #101 also stated the resident is not up for very long daily as he gets upset and wants back in his room and will throw a fit.Registered Nurse (RN #40) (newly hired and still in training) was unsure of where to chart a restraint in the system when asked.Licensed Practical Nurse (LPN #98) (Trainer) was also unable to find where to chart that they preformed the check. 7/23/2025 @1040Don #102 said they was unable to locate any documentation on the releasing and checking on resident every two hours per order. She said when order was placed it wasn't made a task on the system and therefore didn't show up on the TAR (treatment record). She stated she fixed that error and should be resolved going forward. It will now be a task that a nurse has to check off on their charting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 637 Based on record review and staff interview, the facility failed to do a change in condition Minimum [NAME] Set (MDS) after r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 637 Based on record review and staff interview, the facility failed to do a change in condition Minimum [NAME] Set (MDS) after resident #9 developed a pressure ulcer, and correctly documented on the MDS from 6/26/25 the status of Resident #9's injuries. This failed practice was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #9 Facility Census: 56Findings include: 7/22/2025 3:27 PM Record Review MDS on 6/29/25 -section m0210 states that there is an unhealed Pressure Ulcer (PU) / injury section M0300does not state PU stg(stage) 4 or unstageable on left 4th toe, or that it is resolvedwas not resolved until 6/30 according to charting States there is a deep tissue injury (no location given) Section M1040 stated there were no other wounds (Z) is markedL(left) foot 3rd toe abrasion was not resolved until 6/30 Wound note review6/6/25 there was a wound found on L 4th toe found by Registered Nurse (RN #3). 6/9/25 was re assessed by Registered Nurse (RN#44) and ordered updated6/16/25 weekly assessment done by RN #44, cont. treatment for L 4th toe6/23/25 weekly assessment done by RN #3, cont. treatment of L 4th toe. Left 3rd toe noted to have eschar.6/30/25 weekly assessment done by RN #44, noted Left 3rd and 4th toe injuries are resolved. InterviewDirector of Nursing (Don #102) Stated she is aware of some consistency issues when charting wounds on both in house forms and the MDS. Different nurses call wounds by different names sometimes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately . This failed practice was found true for 2 of 5 re...
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Based on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately . This failed practice was found true for 2 of 5 residents reviewed for the PASRR care area during the Long Term Care Survey. Resident Identifier: #2 and #23 Facility Census: 56 Findings include: a) Resident #2 During Record review on 07/22/25 of Resident #2's most recent PASRR completed on 02/17/25 which revealed no diagnosis were checked. Further record review of Resident#2's medical diagnosis revealed they were diagnosed with Bipolar Disorder on 04/21/25 as Primary DiagnosisAn interview with the Social Worker on 07/27/25 at 11:30 am was completed and confirmed Bipolar Disorder was not marked on Resident #2's PASRR. b) Resident #23During Record review on 07/23/25 of resident #23's medical diagnosis revealed the following diagnoses Anxiety disorderSchizoaffective disorderDepression, unspecifiedFurther record review on 07/23/25 of resident #23's PASRR revealed Major Depression was checked. Further research regarding Major Depression and Depression on Psych Central webpage found the following definition Unspecified depressive disorder is a diagnostic term. It means you show symptoms characteristic of a depressive disorder, but they don't meet the specific criteria for more common depressive disorders, such as major depressive disorder. (https://psychcentral.com/depression/unspecified-depressive-disorder#definition)During an interview on 07/23/25 at approximately 11:45 AM the Social Worker stated If they have a diagnosis for Depression i mark Major Depression on the PASRR confirmed Depression should be checked under Other on the PASRR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
657 Based on staff Interviews, Record review and Policy review the facility failed to follow established care plan and order of the resident and ensure they were checked on every two hours . This fail...
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657 Based on staff Interviews, Record review and Policy review the facility failed to follow established care plan and order of the resident and ensure they were checked on every two hours . This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #7 Facility Census: 56This standard of care was NOT MET as evidenced by:Findings include:Record review:07/23/2025 10:00 AM Orders placed on 2/3/25Release seatbelt every two hours, reposition, skin checks, proper attachment of seat belt and pericare.Special Instructions: prevent skin breakdown.Every 2 Hours07:00, 09:00, 11:00, 13:00, 15:00, 17:00no documentation showing release belt and checking of resident every two hours as per orderresident #7 unable to self release belts due medical conditions. This is considered a restraint when a patient can not release belt by themselves.Don #102 stated that she would look into the matter and bring me any documentation they find.Interviews:7/23/2025 @1030 Interview with CNA and nurse on hall with residentCNA #101 stated when he is up we check on him every 2 hours, but CNA's don't have a place to chart it. CNA #101 also stated the resident is not up for very long daily as he gets upset and wants back in his room and will throw a fit.RN #40 (newly hired and still in training) was unsure of where to chart a restraint in the system when asked.LPN #98 (Trainer) was also unable to find where to chart that they preformed the check. 7/23/2025 @1040Don #102 said they was unable to located any documentation on the releasing and checking on resident every two hours per order. She said when order was placed it wasn't made a task on the system and therefore didn't show up on the TAR (treatment record). She stated she fixed that error and should be resolved going forward. It will now be a task that a nurse has to check off on their charting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on Record review and Staff interview, the facility failed to maintain medical records on each resident by not noting residents received Pharmacy Reviews/ Recommendations for the month of June, 2...
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Based on Record review and Staff interview, the facility failed to maintain medical records on each resident by not noting residents received Pharmacy Reviews/ Recommendations for the month of June, 2024. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the long term care facility. Facility Census: 56 Findings Include: During Record review on 07/23/25 it showed residents did not have a Pharmacy Recommendation or review for the month of June, 2024. for Resident's #2, #6, and #18.During an interview with the Director of Nursing (DON) on 07/23/24 at 10:00 AM who stated ( I think that was around the time i took this position and they were done i have the list, i just did not note it in the resident's chart. At this time the DON provided surveyors with a list of residents who had Pharmacy reviews/Recommendations for the month of June, 2025. The report was from the Pharmacy and showed residents #2. #6. and #18 did actually have Pharmacy Reviews/ Recommendations done for the month in question. At this time the DON confirmed it should have been noted in the residents chart that they received pharmacy reviews.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 609 Based on staff Interviews, Record review and Policy review the facility failed to report possible abuse allegations to state...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 609 Based on staff Interviews, Record review and Policy review the facility failed to report possible abuse allegations to state agencies within the two hours time frame. This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #1 Facility Census: 56 This standard was NOT MET as evidenced by: Based upon Staff and Resident Interviews, Record review and Policy review the facility failed to notify State Agencies of the abuse allegation with in the two hours times frame per the CMS guidelines.Findings include: 07/21/2025 1156:InterviewSpoke with resident #1 during interview and she stated there was no issues and everything was good. 07/21/2025 12:47 PM Record reviewDuring record review there was a note placed by SW #17 stating an incident took place that the resident was reluctant to come forward with.attached is the note from the patient chart. Entry was made on 7/21/2025 @ 12:21pm by Social Worker SW#17(as written in chart) Met with (Residents name her) after receiving information from PT that she had expressed concerns with a staff member. (Residents name her) was hesitant at first to talk about the issue and repeatedly stated I don't want to get her in trouble. After some reassurance, she did report having a blonde hair staff member talk a little bit hatefully to her and feels it was because she had soiled her brief. (Residents name her)could not tell Social Worder (SW) anything aside from the color of the aide's hair and that it happened a couple days ago. Reassured her that I would speak with Director of Nursing (DON) in an attempt to determine who the staff member may have been so that education can be provided. Asked (Residents name her)[NAME] if the aide was present in the facility today and she states 'no'. The facility had until 2:21PM on 7/21/2025 to notify state agencies of a potential abuse incident. 07/22/2025 1:13 PMInterviewSpoke with resident #1 again today and she stated I am upset and was crying about how I was made to feel. the tall blond aide with a ponytail, yelled at me because I had an accident, that's not rightPolicy review Upon review of the facility policy for reporting allegations of abuse on Page 5, Section 5 titled INVESTAGATION / REPORTING ; it states that all violations must be reported immediately, but no later than two hours after the allegation is made.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
F0880S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent...
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F0880S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This Standard is NOT MET as evidenced by: Based upon Random observation of lunch cart and Staff Interview, the facility failed to maintain a clean and sanitary transportation of resident meals on tray carts. During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. There was also a Styrofoam cup on top of cart that was next to the spoon, intended for a resident meal. Census:56Finding include: 07/22/2025 12:40 PM Observations:During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. There was also a Styrofoam cup on top of cart that was next to the spoon, intended for a resident meal. 07/22/2025 12:50 PMInterview:Dietary Supervisor #67 was questioned and she stated that the cup was for a resident and that it was placed on top d/t it not fitting in the tray cart. When asked about how the staff knows who's cup that is, she said its on his meal ticket. I confirmed it was on the residents meal ticket for the cup of soda. It stated soda in cup on top of meal cart. When asked about the spoon she said well shoot and took it off the top and when into the kitchen with it.This confirmed the spoon was not supposed to be there and not inline with standards of practice.
Oct 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
.
Based on facility documentation and staff interview, the facility failed to re-evaluate Resident #27's ability to remove a physical restraint easily. This is true for one (1) of one (1) reviewed for...
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Based on facility documentation and staff interview, the facility failed to re-evaluate Resident #27's ability to remove a physical restraint easily. This is true for one (1) of one (1) reviewed for restraints, during the long-term care survey process. Resident I
identifier: #27. Facility census: 45.
Findings included:
a) Resident #27
Observation of a Merry [NAME] outside Resident #27's room, during the initial tour on 10/02/23 at 2:08 PM.
During a medical record review on 10/03/23 at 10:32 AM of Resident #27's order form 09/21/21 revealed:
-Release from the merry walker offer toilet or ambulation every 2 hours.
-Resident may be up in merry walker for safe ambulation throughout the facility.
Continued review of Quarterly Minimum Data Set (MDS) assessment on 08/24/23 Section P, Restraints and Alarms, indicated no physical restraints.
During an interview on 10/03/23 at 11:38 AM the Minimum Data Set Nurse (MDS) #70 stated that Resident #27's Merry [NAME] is not considered a physical restraint because she can remove it herself. The MDS Nurse #70 was asked to provide the evidence of the assessments. No evidence was provided prior to exiting the facility.
On 10/03/23 at 1:19 PM, the MDS Nurse #70 stated they would re-evaluate Resident #27's ability to remove a physical restraint easily.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to transmit a discharge assessment with the Assessment Referen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to transmit a discharge assessment with the Assessment Reference Date (ARD) of 05/02/23 for Resident #14. This was true for one (1) of three (3) discharges reviewed during the survey process. Resident identifier: #14. Facility census: 45.
Findings included:
a) Resident #14
On 10/03/23 at 11:15 AM, a record review was completed for Resident #14. The resident was admitted to the facility on [DATE] and discharged on 05/02/23. The review found the discharge Minimum Data Set (MDS) had not been transmitted upon the discharge date of 05/02/23.
On 10/03/23 at 12:40 PM, an interview was held with Clinical Supervisor #70. The Clinical Supervisor #70 stated, the discharge (return not anticipated) assessment dated [DATE] is in process now .I missed it .it needed submitted .I just completed it today.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to revise a care plan regarding an actual fall with injury and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to revise a care plan regarding an actual fall with injury and discontinued medications for Resident #34. This was true for one (1) of 5 (five) residents reviewed under the care areas of accidents and unnecessary medications during the survey process. Resident identifier: #34. Facility census: 45.
Findings included:
a) Resident #34
Fall with injury.
On 10/02/23 at 1:12 PM, a record review was completed for Resident #34. The review found the resident had one (1) documented fall with injury on 08/12/23 resulting in a left proximal femur fracture.
A progress note dated 08/12/ 23 at 3:06 PM stated the following: Resident was heard fall in her room. When we got to the room she was laying in the doorway saying that her hip was hurting. She was laying on her left side. She was placed on back board and gurney and transferred to the ED (Emergency Department) for further evaluation. She said she was going to the bathroom and ran into the doorway. All necessary paperwork sent with her. (Name of Health Care Surrogate) was notified on transfer. Resident was transferred to (Name of acute care facility). She has a fractured left proximal femur. (Name of facility physician) called to get information. (Name of Health Care Surrogate) was notified. discharged from ED (emergency department) at 1420 (2:20 PM). (Typed as written.)
The quarterly Minimum Data Set (MDS) review dated 08/22/23 section J indicated multiple falls were documented throughout this timeframe. The falls were listed as follows:
--1 (one) with no injury
--2+ (two plus) injury except major
--1 (one) major injury
The care plan was reviewed on 10/02/23 at 2:00 PM, which listed the focus area as potential for injury from falls as evidenced by (AEB) unsteady gait; and the resident did have an actual fall with a major injury. The goal stated resident will incur no serious injuries from falls through the next evaluation.
A reportable dated 08/12/23 completed by the facility regarding the actual fall with injury was reported to the appropriate state agencies as required. The statement included in the reportable was Resident went to (Name of acute care facility) for repair surgery. Resident returned to the facility on [DATE]. Resident will continue to receive all care as needed. (Typed as written.)
On 10/03/23 at 2:20 PM, an interview with the Clinical Supervisor #70 which stated, It's not been updated .I haven't updated any care plans recently.
No further information was obtained during the survey process.
b) Discontinued medications.
On 10/03/23 at 2:00 PM, a review of unnecessary medications was completed for Resident #34. The current physician's orders were reviewed. The current physician's orders did not include Seroquel (antipsychotic) which was discontinued on 09/09/23 and Melatonin (supplement) which was discontinued on 09/06/23. However, the care plan lists interventions stating, Administer med (medication) Seroquel 25 mg (milligram) daily and melatonin 3 mg at bedtime as ordered by physician under the focus area of mood problem related to depression as evidenced by irritability, sad affect, crying/tearfulness, angry outbursts, hopelessness, withdrawn, etc. Resident has elopement behaviors with agitation. Resident is prescribed anti-psychotic and anti-depressant medications. (Typed as written.)
On 10/03/23 at 2:20 PM, an interview was held with the Clinical Supervisor #70 which stated, It's not been updated .I haven't updated any care plans recently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
.
Based on medical record review, family interview and staff interview, the facility failed to provide care required to maintain good hygiene to a resident who was dependent for Activities of Daily Li...
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Based on medical record review, family interview and staff interview, the facility failed to provide care required to maintain good hygiene to a resident who was dependent for Activities of Daily Living (ADL) care one (1) of one (1) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #36. Facility census: 45.
Findings included:
a) Resident #36
During an interview on 10/02/23 at 2:35 PM, Resident #36's wife stated He has not had a shower due to COVID outbreak. I was in today and gave him one, or it probably would have been a couple more weeks. He needs to be out of bed at least a couple hours a day but they are not doing that either.
A review of the facility shower schedule on 10/03/23 at 10:35 AM revealed Resident #36's showers are scheduled for every Tuesday and Saturday.
Scheduled for the following:
-09/30/23
-09/26/23
-09/23/23
-09/19/23
-09/16/23
-09/12/23
-09/09/23
-09/05/02
-09/02/23
Further review of the medical record revealed Point of Care Bathing was coded received shower on the following days:
-09/23/23
-09/19/23
-09/12/23
-09/05/23
-09/02/23
Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/14/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing
A. Bathing: Self Performance coded 4) Total dependence.
B. Bathing: Support provided coded 2) one-person physical assist.
During an interview on 10/03/23 at 1:58 PM the DON stated, There is no reason why he has not received a shower.
The DON acknowledged Resident #36 did not receive the care required to maintain good hygiene and requires assistance with ADL's.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, medical record review, family interview and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to follow physician orders...
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Based on observations, medical record review, family interview and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to follow physician orders for Resident #36 to be up in a wheelchair daily and Resident #36 Restorative nursing three (3) times a week. This was true for one (1) of 12 residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: Resident #36. Facility census: 45.
Findings included:
a) Resident #36
During the initial tour on 10/02/23 at 11:35 AM Resident #36 was lying in bed watching TV.
During an interview on 10/02/23 at 2:35 PM Resident #36's wife stated, He needs to be out of bed for at least a couple hours a day but they are not doing that either.
During a record review on 10/02/23 at 7:30 PM Resident #36 medical record review revealed a Physician order dated 05/09/23 up in wheelchair w/c daily with footrest. Every Shift: Day and Evening.
Further record review revealed Residents #36 Point of Care Activities of Daily Living (ADL) transfer documentation was coded 8) Activity did not occur on the following days:
-10/02/23
-10/01/23
-09/30/23
-09/29/23
-09/28/23
-09/27/23
-09/26/23
-09/25/23
-09/22/23
-09/15/23
-09/14/23
-09/13/23
-09/10/23
-09/08/23
During an observation on 10/03/23 at 9:20 AM Resident #36 was lying in bed watching TV.
During an observation on 10/03/23 at 12:15 PM Resident #36 was lying in bed and appeared to be resting.
During an interview on 10/03/23 at 1:58 PM, the Director of Nursing (DON) stated There is no reason why he should not be up in a wheelchair, he can watch TV in his room instead of in his bed.
The DON acknowledged the physician order for Resident #36 to be in a wheelchair daily was not being followed.
During an observation on 10/03/23 at 3:30 PM Resident #36 was lying in bed watching TV.
During an observation on 10/04/23 at 11:15 AM Resident #36 was lying in bed watching TV.
The DON acknowledged the physician order for Resident #36 to be in a wheelchair daily was not being followed.
b) Resident #36
During a record review on 10/02/23 at 7:30 PM Resident #36 medical records revealed a Physician order dated 07/27/23 Restorative nursing three (3) times a week for ROM (Range of Motion)/Stretching to both lower extremities for maintenance of ROM and worsening contractures.
Further record review revealed Residents #36 Point of Care (ADL) Restorative Nursing Minutes documentation was coded No Restorative Nursing Data Recorded on the following days:
-10/02/23
-10/01/23
-09/30/23
-09/29/23
-09/28/23
-09/26/23
-09/25/23
-09/24/23
-09/23/23
-09/22/23
-09/21/23
-09/20/23
-09/19/23
-09/18/23
-09/17/23
-09/16/23
-09/15/23
-09/14/23
-09/13/23
-09/11/23
-09/10/23
-09/09/23
-09/08/23
-09/06/23
-09/05/23
-09/04/23
-09/03/23
-09/02/23
During an interview on 10/03/23 at 1:58 PM the DON stated, We have not done restorative since the COVID outbreak, we have been limited. The restorative nurse had COVID and was out for five (5) days. Before that she was off two (2) months for surgery. She is our only restorative aide, so nothing gets done.
The DON acknowledged the physician order for the Restorative three (3) times a week was not being followed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to dispose of expired medications stored in the medication room. This was a random opportunity for discovery. Facility census: 45.
a) Me...
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Based on observation and staff interview, the facility failed to dispose of expired medications stored in the medication room. This was a random opportunity for discovery. Facility census: 45.
a) Medication Room
On 10/03/23 at 10:00 AM, a tour of the medication room was completed. Within the over-the-counter medications, two (2) bottles of Oyster Shell Calcium 500 mg (milligram) plus Vitamin D were found to be expired in July 2023.
On 10/03/23 at 10:06 AM, the Director of Nursing (DON) was notified and confirmed the two bottles were expired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
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Based on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-determination through support of resident choice regarding having access t...
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Based on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-determination through support of resident choice regarding having access to the dining room during meals and activities. This failed practice had the potential to affect an unlimited number of residents currently residing in the facility. Facility census: 45.
Findings included:
A review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation- COVID-19 with a revision date of 05/08/23 read as follows.
.Communal Activities, Dining and Resident Outings:
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
a) Resident #11
During an interview, on 10/02/23 at 11:52 AM, Resident #11 stated, I always eat in the dining rooms, but we have to eat in our rooms since COVID.
During an observation on 10/02/23 at 12:00 PM residents were not in the dining rooms for the noon meal.
b) Interviews
During an interview on 10/03/23 at 11:39 AM, the Activity Volunteer Coordinator (AVC) #68 stated the Residents have not eaten in the dining room and/or the activity area since the shut down due to COVID and was sometime in the middle of September.
During an interview on 10/03/23 at 11:42 AM, the Director of Nursing (DON) stated we have been on lock down due to COVID since 09/11/23. We did not have group activities or communal dining. I have been following the CMS guidelines.
The DON was asked Have you read the updated revision of the CMS guidelines?. No response was given.
During an observation, on 10/04/23 at 9:14 AM, there were a few residents sitting in the dining area and a few residents in the activity area.
During an interview on 10/04/23 at 9:25 AM, the DON stated I read the CMS guidelines and we are now open for group activities and communal dining. The Infection Preventionist is the one that shut us down, not me. I was following her direction.
The DON acknowledged that communal dining should have taken place during the COVID outbreak according to the CMS guidelines.
During an interview on 10/04/23 at 10:54 AM, The Infection Preventionist (IP) #113 stated on 09/11/23 one (1) resident was asymptotic and tested positive. Then we tested all the residents and staff, I think it was eight (8) residents that tested positive. We started N-95 and goggles and stopped all group activities and communal dining.
The IP was asked Do you know what the CMS guidelines are for group activities and communal dining when a COVID outbreak is present? The IP #113 stated I did not know about it. I am used to working in the hospital. I am updated now.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
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Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and sup...
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Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This failed practice had the potential to affect an unlimited amount of residents residing in the facility. Resident Identifiers: Resident #11. Facility census: 64.
Findings included:
A review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation- COVID-19 with a revision date of 05/08/23 read as follows.
.Communal Activities, Dining and Resident Outings:
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
a) Resident #11
During an interview on 10/02/23 at 11:52 AM, Resident #11 stated I usually attend all the activities but since COVID we have not had any in a long time. I am so bored in my room.
During a record review on 10/03/23 at 7:59 PM, Resident #11's medical record revealed an activity participation record with the following notes:
-dated 09/21/23 Staff talked with Resident from outside his COVID room.
-dated 09/27/23 staff talked with resident from doorway. Resident is just not very happy dealing with the COVID restrictions. :(Typed as written)
Further review of medical records revealed a activity participation record for the month September 2023
On the following dates no activities participation was coded:
-09/14/23
-0918/23
-09/24/23
On the following dates Conversation on phone:
-09/15/23
-09/16/23
-09/19/23
-09/20/23
-09/22/23
-09/26/23
-09/28/23
-09/29/23
-09/30/23
On the following dates One to One and TV were coded:
-09/12/23
-09/13/23
-09/15/23
-09/16/23
-09/17/23
-09/19/23
-09/20/23
-09/21/23
-09/22/23
-09/23/23
-09/25/23
-09/26/23
-09/27/23
-09/28/23
-09/29/23
-09/30/23
b) Observations
During an the initial tour of the facility on 10/02/23 at 11:35 a review of the monthly activity calendar revealed the group activities for 10/03/23 as follows:
-12:00 PM Lunch Bunch
-2:00 PM Bingo
-5:00 PM Supper Club
-7:00 PM (A person's name) Show
During an observation on 10/02/23 at 12:00 PM residents were not in the dining rooms for the noon meal.
During an observation on 10/02/23 at 2:00 PM The Dining Area/Activity Area were void of any resident participating in bingo.
c) Interviews
During an interview on 10/03/23 at 11:39 AM the Activity Volunteer Coordinator (AVC) #68 stated We have not had group activities since the shut down due to COVID, that was sometime in the middle of September.
During an interview on 10/03/23 at 11:42 AM the Director of Nursing (DON) stated we have been on lock down due to COVID since 09/11/23. We have not had group activities or communal dining. I have been following the CMS guidelines.
The DON was asked Have you read the updated revision of the CMS guidelines?. No response was given.
During an interview on 10/04/23 at 9:14 AM, AVC #68 stated we just opened back up today. I was helping a resident get a drink. We have not had group activities since 09/11/23 due to the COVID outbreak. When the residents are in isolation for COVID we stand at the door and visit, we have not been going into the rooms so we don't spread it to the other units. The residents that are not on COVID isolation have provided in room activities such as arts and crafts, bible study, manicures, read the newspaper and 1:1 visits.
The AVC #68 was asked Do you or your staff not go into the COVID isolation residents rooms to supply them with any type of activity?. The AVC stated No.
The AVC #68 acknowledged that all residents should have been given the choice to participate in a group and/or in room activities.
During an interview on 10/04/23 at 9:25 AM, the DON stated I read the CMS guidelines and we are now open for group activities and communal dining. The Infection Preventionist is the one that shut us down, not me. I was following her direction.
The DON acknowledged that group activities should have taken place during the COVID outbreak according to the CMS guidelines.
During an interview on 10/04/23 at 10:54 AM The Infection Preventionist (IP) #113 stated On 09/11/23 one (1) resident was asymptotic and tested positive. Then we tested all the residents and staff, I think it was eight (8) residents that tested positive. We started N-95 and goggles and stopped all group activities and communal dining.
The IP was asked Do you know what the CMS guidelines are for group activities and communal dining when a COVID outbreak is present? The IP #113 stated I did not know about it. I am used to working in the hospital. I am updated now.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to dispose of expired food i...
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Based on observation, policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to dispose of expired food items. The facility also failed to accurately document the nourishment room refrigerator temperature log. This failed practice had the potential to affect all residents currently receiving nourishment from the nourishment room and the Resident's food storage refrigerator. Facility census: 45.
Findings included:
A review of the facility policy titled Temperature Control with a revision date of 01/17 read as follows:
.Procedure: Proper temperature control is a necessary practice to prevent possible food spoilage or bacterial growth, which could result in a food-borne illness.
1. Temperature records are maintained for all refrigeration and freezer units both in the Dietary Department and on patient care areas (Diet Kitchens). The Dietary Department personnel are responsible for checking and recording temperatures daily.
a) Nourishment Room
During a tour of the nourishment room on 10/03/23 at 11:19 AM with the Dietary Manager revealed the following issues:
- 28 sugar free Jello with an expired manufacture date
-a container of mac and cheese with an expired manufacture date of 08/22/23.
The Dietary Manager (DM) acknowledged the failure to discard those that were out of date. The DM stated we stock the refrigerator, but we don't check the food for expiration.
During an interview on 10/03/23 at 11:35 AM, the Director of Nursing (DON) stated The dietary is supposed to check the expiration date the nursing staff does not do that.
b) The Resident Food Storage Refrigerator
Refrigerator Temperature Log
A review of the September 2023 Resident Storage Refrigerator Temperature Log on 10/03/23 at 11:35 AM, revealed the documentation was incomplete. The refrigerator and freezer were void of temperatures for the following dates:
-09/30/23
-09/29/23
-09/13/23
-09/09/23
-09/08/23
An immediate interview with DM, acknowledged the refrigerator temperature log was incomplete and should have been completed daily and stated that the Activity staff is responsible for the temperatures in the resident's food storage refrigerator.
During an interview on 10/03/23 at 11:39 AM the Activities Volunteer Coordinator (AVC) #68 stated the Activity staff date and label the resident's food when it comes in, we also are responsible for checking the refrigerator/freezer temperatures daily.
The AVC #68 acknowledged the refrigerator temperature log was incomplete and should have been completed daily. The AVC #68 stated that we have been forgetting to do the temperatures since we have been on lock down.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
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Based on facility documentation and staff interview the facility failed to have required members attend and participate in the Quality Assessment and Assurance (QAA) meetings. This failed practice ...
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Based on facility documentation and staff interview the facility failed to have required members attend and participate in the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 45.
Findings included:
a) QAA
Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no certified Infection Preventionist (IP), Administrator/ Chief Executive Officer (CEO), or the Medical Director attended the meeting quarterly.
During an interview 10/04/23, at 1:38 PM the CEO verified the required members were not in attendance for the quarterly QAA meetings.
No other information was provided prior to the end of the survey on 10/04/23.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment...
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Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation during the noon meal, resident hand hygiene was not performed. This had the potential to affect more than a limited number of residents. Facility census: 45.
Findings included:
a) Hand Hygiene
During a dining observation on 10/03/23 beginning at 12:11 PM, this surveyor observed several wet washcloths in a trash bag. The Cardinal Way noon meal trays arrived at 12:15 PM.
Nurse Aide (NA) #2 and the Director of Nursing (DON) were observed passing four (4) lunch trays. During the observations hand hygiene was not offered to the residents prior to receiving their noon meal trays. This surveyor intervened and inquired about hand hygiene.
During the observation no hand hygiene was provided to the residents prior to the noon meal being served. After several resident trays were delivered, this surveyor intervened.
Hand sanitizer wipes were not placed on the meal trays. There were no hand sanitizer bottles observed near the serving areas.
During an interview on 10/03/23 at 12:19 AM (NA) #2 stated, I am supposed to use the washcloths in the bag to wash the residents' hands but I have not had time to do it. NA #2 was asked what is on the washcloth? NA #2 stated hot water.
NA #2 acknowledged the resident did not receive hand hygiene prior to their noon meal.
During an interview on 10/03/23 at 12:22 PM, the DON was asked how did you sanitized the residents' hands prior to noon meal delivery? The DON stated the washcloths were used and they have peri wash on them. The DON said, We wipe the residents' hands. This surveyor informed the DON that hand hygiene was not provided, and the washcloths only had hot water on them per NA #2.
The following Residents had received their noon meal trays prior to hand hygiene:
-Resident #3
-Resident #26
-Resident #12
-Resident #20
-Resident #39
-Resident #37
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Apr 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to use a barrier during a medication pass and failed to post signage on a transmission based precaution (TBP) room. This was a random op...
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Based on observation and staff interview, the facility failed to use a barrier during a medication pass and failed to post signage on a transmission based precaution (TBP) room. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifiers: Resident #192. Facility census 42.
Findings included:
a) Resident #192
On 04/18/22 at 1:40 PM, an observation of Resident #192 who was on TBP and had personal protective equipment (PPE) in a caddy holder on the door. There was no signage on Resident #192 door to explain what PPE to utilize before entering room or what precautions to use.
An interview on 04/18/22 at 1:45 PM, with Nurse Aide (NA) #13 regarding how NA #13 would know what PPE to use when entering Resident #192 room. NA #13 stated I think airborne.
At 1:50 PM on 04/18/22, an interview with the Director of Nursing (DON) stated Yes, there should be a droplet precaution sign on the door. We have signs at the nurses station, so I don't know why the signage was not placed on the door.
b) Medication administration
During an observation of medication administration on 04/19/22 at 9:14 AM, Registered Nurse (RN) #91, entered Resident #17's room with the morning medications. RN #91 placed the following medications on the bedside table without a barrier: Atrovent aerosol with spacer, Azelastine eye drops, and saline nasal spray. RN #91 administered the morning pills, then the inhaler followed by the eye drops and nasal spray. RN #91 returned the Atrovent aerosol, the spacer, the eye drops and nose spray to the cart without any attempts to clean or sanitize.
The above observation was reviewed with RN #91 during an interview at 9:15 AM on 04/19/22. RN #91 agreed she should have placed a barrier between the medications and the bedside table and acknowledged she contaminated the medication cart by placing the contaminated items back into the medication cart.
The Director of Nursing confirmed a barrier should be used during medication administration to prevent contamination during an interview on 04/19/22 at 9:30 AM.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observation, interviews, record review and policy review the facility failed to ensure bottles of insulin vials were locked and secured in a medication cart. This was a random opportunity f...
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Based on observation, interviews, record review and policy review the facility failed to ensure bottles of insulin vials were locked and secured in a medication cart. This was a random opportunity for discovery. The failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #2, #23, #34 and #39. Facility census: 42.
Findings included:
Record review of the facility's policy titled Administration of Medications, revised on 10/2021, showed all medications are stored and locked when walking away from medication cart.
a) Resident #2
An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. One (1) insulin bottle stated Resident #2's name and was a Lantus insulin vial.
During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated that everyone else leaves the insulin bottles out on top of the medication carts too.
During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated that insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart.
During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated that the insulin vials should have been locked up in the medication cart.
A review of Resident #2's medical record showed an physician order for Lantus; give 12 units sub-Q daily-Once A Day at 9:00 AM.
b) Resident #23
An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #23's name and was a Humalog Mix U-100 insulin vial.
During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too.
During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart.
During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart.
A review of Resident #23's medical record showed an physician order for Humalog Mix U-100 give 36 units in the morning once a day at 8:30 AM.
c) Resident #34
An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #34's name and was a Humalog Solution U-100 insulin vial.
During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too.
During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart.
During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart.
A review of Resident #34's medical record showed an physician order for Humalog Solution give U-100; Three times a day at 6:00 AM, 11:30 AM, 5:30 PM.
d) Resident #39
An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #39's name and was a Humalog Solution U-100 insulin vial.
During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too.
During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart.
During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart.
A review of Resident #39's medical record showed an physician order for Humalog Solution give U-100: Before meals and at bedtime at 7:00 AM, 11:00 AM, 5:00 PM and 10:00 PM.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, staff interview, and record review, the facility failed to ensure the ice machine was in good, clean working order. In addition, the facility failed to ensure opened food items...
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Based on observation, staff interview, and record review, the facility failed to ensure the ice machine was in good, clean working order. In addition, the facility failed to ensure opened food items included the date opened by the facility staff. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 42.
Findings included:
a) Ice Machine
On 04/18/22 at 10:48 AM, the initial tour of the kitchen with Dietary Manager (DM) #29 found the ice machine had a pink film on the inside lip. DM #29 stated, maintenance cleans the ice machine on a cleaning schedule. DM #29 said she was going to alert maintenance immediately.
On 04/19/22 at 11:00 AM, the Maintenance Director (MD) #59 provided a cleaning schedule for the ice machine in the kitchen. MD #59 stated the ice machine is utilized a lot causing the door of the ice machine to be opened and closed throughout the day. The ice machine is cleaned on a quarterly basis. Observation of the cleaning schedule found the machine was cleaned in August 2021.
b) Freezer
On 04/18/22 at 10:48 AM, observation of the walk-in freezer with the DM #29 found the following items were opened and did not contain the date opened by staff:
--one (1) 24 package of frozen biscuits
--one (1) 1/2 bag of 12 meatballs
--one (1) 1/2 bag of 40 unbaked cookies
--one (1) package of peanut butter and jelly sandwich's
--one (1) piece of fish in a Ziploc bag
--one (1) 1/2 package of 12 pieces of French toast
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
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Based on policy review and staff interview, the facility failed to update the pneumonia policy in accordance with national standards of practice. The policy does not address the current recommendati...
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Based on policy review and staff interview, the facility failed to update the pneumonia policy in accordance with national standards of practice. The policy does not address the current recommendations for the administration of the Pneumococcal conjugate vaccine (PCV) 15 and 20. This failed practice had the potential to affect more than a limited number of residents Facility census: 42.
Findings included:
a) Pneumonia Policy
A review of the facility policy titled, Immunization Protocol, Adult-Pneumococcal and Influenza Procedure with a revision date of 10/25/2017, found the policy not updated to match the Center of Disease (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. The facility's current policy addresses the administration of Pneumococcal conjugate vaccine (PCV) 13 and the Pneumococcal polysaccharide vaccine (PPSV23). The policy does not address CDC's current recommendation to administer the PCV15 or PCV20.
CDC follows the ACIP recommendations for vaccinations and updates the vaccine schedule based on ACIP guidelines. In 2019, the ACIP updated its recommendations on PCV 13 vaccine scheduling in older adults, noting the vaccine is no longer routinely recommended for all adults age >65 years.
During an interview on 04/19/22 at 10:49 AM, the Director of Nursing confirmed the facility's current pneumonia policy does not identify CDC's current recommendations for the PCV 15 and PCV 20.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Mansfield Place's CMS Rating?
CMS assigns MANSFIELD PLACE an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Mansfield Place Staffed?
CMS rates MANSFIELD PLACE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 50%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Mansfield Place?
State health inspectors documented 23 deficiencies at MANSFIELD PLACE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 22 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mansfield Place?
MANSFIELD PLACE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 54 residents (about 90% occupancy), it is a smaller facility located in PHILIPPI, West Virginia.
How Does Mansfield Place Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MANSFIELD PLACE's overall rating (3 stars) is above the state average of 2.7, staff turnover (50%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Mansfield Place?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Mansfield Place Safe?
Based on CMS inspection data, MANSFIELD PLACE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mansfield Place Stick Around?
MANSFIELD PLACE has a staff turnover rate of 50%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mansfield Place Ever Fined?
MANSFIELD PLACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Mansfield Place on Any Federal Watch List?
MANSFIELD PLACE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.