Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Care Center Of Mansfie during CMS and state inspections, most recent first.
A facility failed to implement protective boots for a resident as per their care plan, which was intended to maintain skin integrity. Despite physician orders for the resident to wear prevalon boots while in bed, observations showed the resident without the boots on multiple occasions. An STNA confirmed the resident never wore the boots during the day.
A resident with dementia and Parkinson's was improperly transferred using a standing Hoyer lift by a single STNA, contrary to facility policy requiring two staff members. This resulted in the lift arm hitting a hand sanitizer, which then struck the resident's arm.
A facility failed to assess a resident for entrapment risks before installing bed rails, despite the resident's medical conditions such as hemiplegia and seizures. The resident's care plan included bed rails due to fall risk, but no assessment was documented. The facility's policy requires such assessments, which were not conducted.
Failure to Implement Protective Boots for Resident
Penalty
Summary
The facility failed to implement protective boots for a resident as outlined in their care plan, which was designed to maintain skin integrity. The resident, who was admitted with diagnoses including heart failure, spinal stenosis, and dementia, was cognitively intact and required substantial to maximal assistance for footwear. The physician's orders from January 2024 specified that the resident should wear prevalon boots while in bed every shift to prevent redness on the heels. However, observations on three separate occasions in August 2024 revealed that the resident was lying in bed without the boots, which were found on the floor near the bed. An interview with a State tested Nurse Aide confirmed that the resident never wore the boots while in bed during the day.
Improper Use of Assistive Devices During Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate use of assistive devices during resident transfers, which resulted in an accident involving a resident. Resident #41, who has diagnoses including dementia, Parkinson's disease, and heart failure, was observed being transferred by a State tested Nurses Assistant (STNA) using a standing Hoyer lift without the required assistance of a second staff member. During the transfer, the Hoyer lift arm hit a wall-mounted hand sanitizer, causing it to fall and strike the resident's left arm. The facility's policy mandates that two staff members are required when using a standing Hoyer lift, a requirement that was not followed in this instance. The Director of Nursing confirmed the policy and the need for two staff members during such transfers.
Failure to Assess Bed Rail Risks for a Resident
Penalty
Summary
The facility failed to assess a resident for the risks of entrapment associated with the use of bed rails prior to their installation or use. This deficiency affected one resident out of seven who had orders for bed rails. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebrovascular disease, stroke, muscle weakness, and seizures, had no documented assessment for bed rail use in their medical record. Although there was a signed consent form for bed rails, the facility did not conduct a proper risk assessment as required by their policy. The resident's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and a need for substantial to maximum assistance with bed mobility, toileting, hygiene, and transfers, but did not identify bed rails as a restraint. The care plan noted the resident was at risk of falls and had seizures, with interventions including the use of bilateral half-size bed rails. Despite these interventions, the facility's MDS nurse confirmed that no assessment for bed rail use had been conducted for the resident. The facility's policy mandates an assessment for entrapment risks and informed consent prior to bed rail installation, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 107 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jag Healthcare Mansfield | 2.3 mi | ★★★★★ | 0 | 0 |
| Liberty Nursing Center Of Mansfield | 3.1 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 3.8 mi | ★★★★★ | 3 | 0 |
| Arbors At Mifflin | 5.4 mi | ★★★★★ | 0 | 0 |
| Oak Grove Manor | 5.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.