Crystal Care Center Of Mansfie

Based on staff interview and review of the Payroll Based Journal (PBJ) staffing data report, the facility failed to have sufficient staffing. This had the potential to affect all residents who resided in the facility in January 2026. The current census was 60. Findings include:Findings include: Review of the PBJ staffing data report revealed the facility had a one-star staffing rating and was identified to have excessively low weekend staffing for Fiscal Year (FY) Quarter One 2026 (01/01/26 through 03/31/26). Interview on 06/29/26 at 4:00 P.M. with the Administrator verified the facility was aware of the one star staffing rating and the excessively low weekend staffing in quarter one FY 2026. This deficiency represents non-compliance investigated under Complaint Number 3020232.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included heart failure, spinal stenosis, and dementia. Review of the quarterly Minimum Data Set assessment, dated 06/11/24, revealed Resident #55 was cognitively intact and required substantial to maximal assistance from staff for putting on and taking off footwear. Review of Resident #55's physician orders for August 2024 identified an active order dated 01/18/24 for prevalon boots on while in bed, every shift for redness to bilateral heels. Review of the plan of care dated 01/12/24 revealed Resident #55 was at risk for impaired skin integrity related to impaired circulation, impaired mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the medical record for Resident #41 revealed an admission date of 02/01/22. Diagnoses included dementia, Parkinson's disease, and heart failure. Resident #41 had impaired cognition. Review of the care plan dated 09/28/23 for Activities of Daily Living (ADLs) revealed staff were to use a mechanical lift for transferring Resident #41. Observation of 08/28/24 at 4:22 P.M. revealed State Tested Nurses Assistant (STNA) #346 was transferring Resident #41 to her wheelchair out in the hall. STNA #346 was observed using the standing Hoyer (mechanical lift) on her own. As STNA #346 was unhooking the Hoyer arm, it hit the hand sanitizer on the wall and the hand sanitizer fell hitting Resident #41 in her left arm. Interview on 08/28/24 at 4:25 P.M. with STNA #346 stated when using the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of Resident #168's medical record revealed an admission date of 08/03/13. Diagnoses included hemiplegia and hemiparesis, cerebrovascular disease, a stroke, muscle weakness, and seizures. The medical record revealed no evidence of an assessment for bed rails. There was a signed consent form for bed rails dated 08/08/13. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #168 had intact cognition and required substantial to maximum assistance of staff with bed mobility, and was dependent on staff for toileting, hygiene and transfers. The assessment did not identify bed rails as a restraint. Review of the care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's personal needs account total balance revealed the total account balance was $24,603.59 on 05/02/22. The balance included 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) residents whom currently reside in the facility. Review of facility surety bond identified it covered the facility for losses up to $20,000. Interview on 05/04/22 at 7:07 A.M. , with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of Resident #12's medical record revealed an admission date of [DATE], with medical diagnoses including: major depression, hemiplegia, dementia and anemia. Review of the monthly physician's orders for [DATE], revealed an order for a security bracelet place on her wheelchair since [DATE]. The orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review revealed Resident #19 had an admission date of 12/31/16. Resident was discharged to the hospital on [DATE] and returned on 01/17/22. Diagnosis included history of falls, and displaced intertrochanter fracture of right femur. Review of the pressure injury grid dated 01/30/22 (untimed) revealed Resident #19 had acquired a fluid filled blister that was unstageable to the right heel. Review of the MDS assessment dated [DATE], created by LPN #20 revealed under section M skin condition asking does the resident have a pressure ulcer injury? The answer was no. Other ulcers, wound or skin problems? The answer was no. Interview on 05/04/22 at 9:54 A.M., with MDS Nurse, LPN #20, verified the 02/04/22 MDS was incorrect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of Resident #21's medical record revealed an admission to the facility on [DATE], with medical diagnoses including: end stage renal disease with dialysis, depression and diabetes. Review of Resident #21's written plan of care for nutritional aspects revealed an 1500 cubic centimeters (cc) fluid restriction with renal diet. Interview on 05/04/22 at 7:58 A.M., with the Director of Nursing (DON) revealed Resident #21 has not been on a fluid restriction since 10/18/20. The DON stated Resident #21's diet changed from renal to regular on 07/27/20. The DON verified the written plan of care was not accurate for Resident #21 in regards to nutritional issues. 2. Review of the medical record for Resident #19 revealed a re-admission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of Resident #213's medical record revealed an admission date of 04/05/22. Diagnoses included diseases of salivary glands, osteoarthritis, and fracture of lower end of right femur. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact. Resident #213 was total dependence of two for bed mobility and required setup help for meals. Review of the care plan dated 04/07/22 revealed the resident had potential for nutritional impairment, dehydration and significant weight changes. Resident#213 had an activities of living self-care performance deficit-functional impairment related to right femur fracture. Interventions included the resident required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of Resident #31's medical record reveal an admission date of 12/03/21. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included Parkinson's disease, cervical disc disorder, encephalopathy, muscle weakness, and hypertension. Review of the quarterly minimum data set (MDS) assessment, dated 03/04/22, revealed the resident was cognitively impaired. The resident had a documented limitation in Range of Motion (ROM) for both upper extremities (shoulders, elbows, wrists, hands). Review of the Occupational Therapy (OT) evaluation and plan of treatment, dated 02/11/22, revealed the goal of increasing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review for Resident #19 revealed an admission date of 12/31/16 and a re-admission date of 01/17/22. Diagnoses for included history of falls, muscle weakness, and displaced right hip fracture on 01/14/22, with repair on 01/17/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no swallowing disorders and no known weight loss. Resident #19 required supervision with set up help only for meals. Record review of the care plan dated 01/24/22 revealed a potential for nutritional impairment and dehydration due to variable meal intakes. Interventions included a house supplement three times a day, obtain/record weight per facility policy and monitor for significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of Resident #21's medical record revealed an admission to the facility on [DATE], with medical diagnoses including: end stage renal disease with dialysis, depression and diabetes. Review of Resident #21's written plan of care for nutritional aspects revealed an 1500 cubic centimeters (cc) fluid restriction with renal diet. Interview on 05/04/22 at 7:58 A.M., with the Director of Nursing (DON) revealed Resident #21 has not been on a fluid restriction since 10/18/20. The DON stated Resident #21's diet changed from renal to regular on 07/27/20. The DON verified the written plan of care was not accurate for Resident #21 in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop a care plan for one resident with a hand contracture. This affected one resident (#58) of one reviewed for range of motion. The facility census was 68. Findings include: Review of Resident #58's medical record revealed an admission date of 07/19/18 with diagnoses including encephalopathy, muscle weakness, hemiplegia and hemiparesis affecting left non-dominant side, and peripheral vascular disease. Review of Resident #58's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident as having impairment on one side. There was no evidence in the medical record of a are plan for Resident #58's left-hand contracture, or any interventions to prevent further decreases in range of motion Interview on 05/15/19 at 2:07 P.M., with Registered Nurse (RN) #400 verified Resident #58's care plan did not address the resident's hand contracture.