Cycle 1
Health 2024-08-08 · Fire 2024-08-08
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mansfield, TX
Mansfield Medical Lodge
4-star overall rating with 4-star inspections with $6,032 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
301 N Miller Rd, Mansfield, TX
(817) 276-4800
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2007-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,811
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Baseline 20.85% · Performance 20.32% · Measure score 2.41 · Achievement 2.41 · Improvement 0.89
Healthcare-associated infections
0
Baseline 7.50% · Performance 12.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.69
Baseline 81.93% · Performance 63.73% · Measure score 2.69 · Achievement 0 · Improvement 2.69
Adjusted total nurse staffing
0.97
Baseline 2.59 hours · Performance 3.06 hours · Measure score 0.97 · Achievement 0 · Improvement 0.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.44% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 17.8% · Lower 95% interval 9.42% |
| Discharge to community | 39.21% |
50.57%
11.4 pts worse
|
Worse than the National Rate · Eligible stays 112 · Observed rate 32.14% · Lower 95% interval 30.9% |
| Medicare spending per beneficiary | 1.62 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 96.84% |
95.27%
1.6 pts better
|
Numerator 92 · Denominator 95 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 95 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 14 · Denominator 37 |
| Discharge mobility score | 35.14% |
50.94%
15.8 pts worse
|
Numerator 13 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 95 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 12.12% |
7.12%
5 pts worse
|
Worse than the National Rate · Eligible stays 81 · Observed rate 20.99% · Lower 95% interval 8.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 153 |
| Staff flu vaccination coverage | 35.97% |
42%
6 pts worse
|
Numerator 50 · Denominator 139 |
| Discharge function score | 45.95% |
56.45%
10.5 pts worse
|
Numerator 17 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 69.23% |
25.2%
44 pts better
|
Numerator 36 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.3% · Q3 4.3% · Q4 1.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
2.7%
6.8 pts worse
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 5.8% · Q3 7.5% · Q4 14.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.3%
2.2 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
18.9%
4.2 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 18.5% · Q3 16.3% · Q4 12.3% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.2% |
10.8%
9.6 pts better
|
16.7%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.6% |
15.4%
11.8 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
16.1%
7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 6.0% · Q3 10.6% · Q4 9.4% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.8% |
15.0%
11.2 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.2%
0.2 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.4% · Q3 2.5% · Q4 2.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
12.0%
2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 10.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
25.9%
4.6 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 29.0% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-19 · Fire 2023-05-19
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-11 · Fire 2022-03-11
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-06
F · Potential for more than minimal harm
2023-05-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-15
F · Potential for more than minimal harm
2022-03-11
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-03-11
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-03-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-06-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-05
D · Potential for more than minimal harm
2024-09-25
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-21
D · Potential for more than minimal harm
2023-05-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-12
K · Immediate jeopardy
2022-03-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-03-12
K · Immediate jeopardy
2022-03-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-03-12
E · Potential for more than minimal harm
2022-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-29
Penalties and ownership
What sits behind the stars
$6,032
2024-09-25
Fine
Fine · fine $6,032
Fine
Ownership
Decatur Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Caretrust Reit Inc
5% Or Greater Mortgage Interest · Organization
Ctr Partnership LP
5% Or Greater Mortgage Interest · Organization
Pmg Opco - Mansfield LLC
Operational/Managerial Control · Organization
Scroggins, Brian
Corporate Director · Individual
Scroggins, Brian
Corporate Officer · Individual
Tyner, Jonathan
Operational/Managerial Control · Individual
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