Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Insufficient nursing staffing was identified after review of PBJ staffing data and staff interview. The facility had a one-star staffing rating and excessively low weekend staffing for FY Q1 2026, and the Administrator confirmed awareness of the staffing concerns. The deficiency was investigated under a complaint and had the potential to affect all residents in the facility.
Infection control deficiencies were identified when the facility did not track infection trends, did not have EBP signage in place for residents with wounds or indwelling devices, did not ensure PPE was worn during high-contact care, and did not store a catheter bag off the floor. A resident with a catheter and heel wounds had no EBP order and a catheter bag touching the floor, another resident on EBP received care without PPE, and a third resident with a catheter had no EBP sign or order.
Failure to provide adequate nail care and personal hygiene assistance for two residents. One resident with DM, hemiplegia, and severely impaired cognition had long fingernails on a contracted hand that were digging into the palm, despite a care plan for foot/nail monitoring and skin checks. Another resident with dementia and severely impaired cognition was observed with facial hair around the mouth on repeated observations, despite needing staff help with personal hygiene and a care plan focused on ADL support and consistent routines.
Insulin on two med carts was found undated, and some vials/pens lacked resident names. Staff verified the labeling issues and said the insulin should be discarded after 28 days. In addition, an LPN left a resident’s morning meds at the bedside even though there was no order for self-administration or bedside medication storage; the resident was cognitively intact and had depression and major depressive disorder.
Failure to Screen Employees in NAR The facility did not follow its abuse, neglect, exploitation, and misappropriation policy by failing to screen all employees in the Ohio NAR before or on their first day of work. Record review showed no NAR evidence for an LNHA, a dietary aide, and an RN, and the HR manager confirmed only CNAs were being screened. The facility policy required contact with the State's Nurses Aide Registry or other appropriate licensing board for all applicants.
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.
Insufficient Nursing Staffing and Low Weekend Coverage
Penalty
Summary
Provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift was not met. Based on staff interview and review of the Payroll Based Journal staffing data report, the facility failed to have sufficient staffing. Review of the PBJ staffing data report showed the facility had a one-star staffing rating and was identified as having excessively low weekend staffing for FY Quarter One 2026 (01/01/26 through 03/31/26). During an interview on 06/29/26 at 4:00 P.M., the Administrator verified the facility was aware of the one-star staffing rating and the excessively low weekend staffing in quarter one FY 2026. The deficiency was investigated under Complaint Number 3020232 and was noted to have the potential to affect all residents who resided in the facility in January 2026, with a current census of 60.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not adequately tracking resident infections for trends, not ensuring Enhanced Barrier Precautions (EBP) signage was in place for residents who required it, not ensuring staff wore PPE during high-contact care for residents on EBP, and not ensuring indwelling catheter bags were stored appropriately. These findings involved Residents #1, #6, and #49 and were identified through observation, medical record review, review of infection control documents, staff interview, and review of CDC guidance and facility policy. Resident #1 had diagnoses including paraplegia, chronic kidney disease, and cholecystitis, and had an indwelling urinary catheter for urinary retention and neurogenic bladder. The care plan also identified a left heel area of concern and later listed EBP related to a chronic wound and indwelling urinary catheter use, with interventions for gown and glove use during high-contact care. However, there were no physician orders for EBP. During observation, the resident’s catheter bag was underneath the wheelchair and touching the floor, and the LPN confirmed it should be off the floor to prevent infection. The room also had no EBP sign posted and no PPE outside the door. Resident #6 had diagnoses including chronic metabolic acidosis and hydronephrosis, was cognitively intact, and was dependent on staff for ADLs. The care plan identified EBP due to an indwelling urinary catheter and a right heel wound, with gown and glove use during high-contact care, but there were no physician orders for EBP. During observation, a CNA entered the resident’s room without PPE, and later stated the resident had a bowel movement on the bedpan and needed assistance with care. Resident #49 had diagnoses including overactive bladder, dysuria, and anemia, was cognitively intact, and had an indwelling urinary catheter with catheter care listed in the care plan. There was no care plan or physician order for EBP, and the room had no EBP sign posted. Review of infection surveillance showed no monitoring of infection trends from 01/01/26 through 06/29/26, and the IP stated she was not aware she had to track infections that did not meet McGeer’s criteria and confirmed there was no tracking of trends.
Failure to Provide Adequate Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure residents dependent on staff for activities of daily living received adequate nail care and personal hygiene assistance. Resident #5 had diagnoses including anxiety disorder, DM, and hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side. The quarterly MDS showed severely impaired cognition and dependence on staff for personal hygiene. The care plan included interventions for foot care monitoring and weekly skin inspection. However, review of shower sheets showed the last documented nail cleaning and trimming was on 05/26/26, and on 06/28/26 the resident’s fingernails on the left hand were observed to be long and digging into the palm of the hand due to a contracture. A CNA later verified the nails were long and digging into the palm and stated the resident had DM and required the nurse to cut the fingernails. Resident #43 had a diagnosis of dementia and a quarterly MDS showing severely impaired cognition and a need for supervision or touching assistance with personal hygiene. The care plan identified the resident as at risk for ADL decline and included interventions to encourage participation in ADLs and maintain a consistent routine. Despite this, observations on two separate days showed the female resident had facial hair surrounding her mouth. An Activities Assistant later verified the facial hair was still present. The facility policy on resident dignity stated staff would provide care that preserves each resident’s dignity by maintaining personal appearance and hygiene consistent with preferences and the care plan.
Insulin Storage and Bedside Medication Handling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles. During observation of the 100-Hall A medication cart, an insulin Novolin R multi-dose vial for Resident #57 was found without a date when opened, a Novolin R injection pen for Resident #57 was also undated, and a multi-dose vial of Lantus was undated. RN #399 verified that the insulin pens were not dated when opened and stated they should be discarded after 28 days. During observation of the 300-Hall medication cart, a Lispro Kwik Pen for Resident #32 was undated, a Novolog multi-dose vial was undated and did not have a resident name on it, and another Lispro Kwik Pen was undated and also lacked a resident name. LPN #359 verified the insulins were not dated and stated the Novolog was believed to be for Resident #57 while the unlabeled Lispro insulin was believed to be for Resident #32. In addition, Resident #64, who was cognitively intact and had diagnoses including depression and major depressive disorder, had a cup of morning medications with her name on it sitting on the bedside table even though there was no order for self-administration or for medications to be left at bedside. LPN #378 confirmed the medications were the morning medications and stated Resident #64 did not have an order to leave medications at bedside.
Failure to Screen Employees in Nurse Aide Registry
Penalty
Summary
The facility failed to follow its abuse, neglect, exploitation, and misappropriation screening policy by not ensuring all employees were screened in the Ohio Nurse Aide Registry prior to or on their first day of work. Record review showed the Licensed Nursing Home Administrator had a hire date of 01/06/26 with no evidence of a Nurse Aide Registry screen, Dietary Aide #310 had a hire date of 03/12/26 with no evidence of a Nurse Aide Registry screen, and Registered Nurse #399 had a hire date of 10/27/25 with no evidence of a Nurse Aide Registry screen. During interview, the Human Resource Manager confirmed these individuals were not screened in Ohio's Nurse Aide Registry and stated she only screened certified nursing aides. Review of the facility policy titled Resident Abuse, Neglect, Exploitation and Misappropriation of Property stated all individuals applying for employment are screened through contact with the State's Nurses Aide Registry or other appropriate licensing board.
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.
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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) |
|---|---|---|---|---|
| Jag Healthcare Mansfield | 2.3 mi | ★★★★★ | 0 | 0 |
| Liberty Nursing Center Of Mansfield | 3.1 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 3.8 mi | ★★★★★ | 4 | 0 |
| Arbors At Mifflin | 5.4 mi | ★★★★★ | 0 | 0 |
| Oak Grove Manor | 5.4 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.