Crystal Care Center of Mansfie

Inspectors wroteBased on observations, medical record review, review of infection control documents, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure resident infections were adequately tracked for potential trends, failed to ensure residents who required Enhanced Barrier Precautions (EBP) had signage in place to including instructions for use of specific personal protection equipment (PPE), failed to ensure staff wore PPE during high-contact resident care activities with residents in EBP, and failed to ensure indwelling catheters were stored appropriately. This affected Residents #1, #6, and #49 and had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, observation and policy review, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received adequate nail care and personal hygiene assistance. This affected two residents (#5 and #43) of three residents reviewed for ADL care. The facility census was 60.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure insulin medications were labeled appropriately with a date when opened and resident's names were on the medication, and medications were not left at a resident's bedside. This affected two of six medication carts observed for medication storage and the facility identified there were six medication carts in the facility. This affected Residents #32, #57, and #64. The census was 60. Findings Include: 1. Observation on 06/29/26 at 7:41 A.M. of the 100-Hall A medication cart revealed an insulin Novolin R solution multi-dose vial 100 unit per milliliter (ml) with a dispense date from the pharmacy on 05/30/25 was not dated when opened for Resident #57. [...]

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to implement their policy by ensuring all employees were screened in the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. This had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to implement protective boots designed to maintain skin integrity per the plan of care for Resident #55. This affected one (Resident #55) of 19 residents reviewed for care plan implementation. The facility census was 61.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure assistive devices were used appropriately to ensure a safe transfer. This affected one (Resident #41) of four residents reviewed for accidents. The facility census was 61.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to assess the resident for the risks of entrapment with the use of bed rails prior to installation or use. This affected one resident (#168) of seven residents identified with orders for bed rails. The facility census was 61.

Inspectors wroteBased on resident personal needs accounts (PNA) balances review, surety bond review and staff interviews, the facility failed to ensure the surety bond covered the entire balance maintained in the resident PNA account. The facility maintained 44 (#1, #2, #3, #5, #8, #9, #10, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #23, #25, #24, #26, #27, #28, #29, #30, #32, #33, #34, #35, #37, #38, #39, #40, #43, #45, #46, #50, #53, #58, #59, #60, #61, #62 and #214) of 44 personal needs accounts funds. The facility census was 68.

Inspectors wroteBased on observations, review of tracking logs, review of manufacture's instructions and staff interviews, the facility failed to ensure security bracelets used to identify potential elopements were monitored for expiration dates and tracked during nightly checks. This affected seven (#9, #20, #22, #28, #33, #34 and #113) residents whom currently have security bracelets and one (#12) resident who had an expired security bracelet. The facility had four additional spare security bracelets, that were not being tested. The facility also failed to ensure fall interventions were in place for one (#21) of three sampled residents identified high risk for falling. The facility census was 68.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to reflect the residents current condition. This affected one (#19) of 22 residents reviewed for assessments. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a plan of care was revised timely to meet the current needs of the resident. This affected two (#21 and #19) of 22 residents care plans reviewed. The facility census was 68.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and review of policy, the facility failed to ensure a dependent resident was safely and comfortably position to eat while in bed. This affected one (#213) of four residents observed eating in bed. The facility census was 68.

Inspectors wroteBased on review of the medical record, observations, family and staff interviews, and policy review, the facility failed to ensure a resident's range of motion and application of orthotic devices were maintained with continuous restorative care. This affected one (#31) of one resident reviewed for range of motion. The facility census was 68.

Inspectors wroteBased on observations, medical record reviews, and staff interviews, the facility failed to ensure residents were provided supplemental dietary foods to maintain nutritional health. This affected two (#19 and #21) of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on record review, observation, interviews with resident, staff and dialysis center staff, the facility failed to ensure a resident was provided a meal prior to leaving for regular dialysis appointments. This affected one (#21) of one reviewed for dialysis services. The facility identified three current residents receiving dialysis services. Facility census was 68.