Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, medical record review, review of the facility policy, and staff interview, the facility
failed to ensure residents were free of significant medication errors. This affected one (Resident #44) of
three residents observed for medication administration. The facility identified a total of 11 residents received
insulin in the facility. The facility census was 41.
Residents Affected - Few
Findings include:
Review of Resident #44's medical record revealed an admission to the facility occurred on 12/02/21.
Diagnoses included diabetes mellitus and Alzheimer's disease.
Review of the current physician orders for May 2023 revealed medications including; Humalog eight units
before meals, call physician if blood sugar was below 70 or above 400.
Observation of Resident #44 on 05/10/23 at 7:49 A.M. revealed she received her breakfast and was eating
independently. Resident #44 was observed to eat 100% of her breakfast meal on 05/10/23 at 8:08 A.M.
Observation of Licensed Practical Nurse (LPN) #41 on 05/10/23 at 8:53 A.M. revealed LPN #41 gathered
medications for Resident #44 including Humalog insulin pen. LPN #41 stated Resident #44's blood sugar
(BS) level was 92 that morning (05/10/23) and LPN #41 obtained the BS level around 6:00 A.M. LPN #41
administered the Humalog eight units for Resident #44 at 8:57 A.M. LPN #41 confirmed Resident #44's
current physician order for Humalog was to be administered before breakfast. LPN #41 confirmed she did
not follow the physician order.
Review of the facility's policy titled General Guidelines for Medication Administration, dated 03/01/07,
revealed all medication are administered in accordance with written orders of the attending physician.
Medications are administered within 60 minutes of scheduled time, except before or after meals orders,
which are administered precisely as ordered.
This deficiency represents non-compliance investigated under Complaint Number OH00142307.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
365118
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365118
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jag Healthcare Mansfield
50 Blymyer Avenue
Mansfield, OH 44903
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observations, review of facility policy, and residents and staff interviews, the facility failed to
ensure a comfortable water temperature was maintained on the orange unit of the facility. This affected
seven residents (#24, #25, #28, #29, #30, #33, and #35) and had the potential to affect all 22 residents
residing on the orange unit. The facility census was 41.
Findings include:
Interview and observation of the shower room, across from the nursing station on the orange unit was
completed on 05/10/23 at 7:11 A.M. State Tested Nursing Assistant (STNA) #31 was observed in the room
with a resident who she was getting ready to give a shower to. The water in the shower was running at that
time and was tested with a thermometer and was noted to be 90 degrees Fahrenheit (F) and felt luke warm.
STNA #31 stated the facility was having trouble with lack of hot water on the orange unit for a few weeks.
STNA #31 confirmed the facility has been working on it, but it was not fixed. STNA #31 did identify the
facility has a shower room on the purple unit, that does not have issues with hot water temperatures and
staff can take residents there to shower.
Water temperatures were obtained in the bathroom sinks in Residents #24, #28, #29, and #30's rooms on
the Orange Unit on 05/10/23 between 7:22 A.M. and 7:28 A.M. The water was noted to be 90 to 92 degrees
F and felt luke warm. STNA #32 confirmed the water temperatures and confirmed this has been happening
off and on for the past several weeks.
Observation of the orange nursing station on 05/10/23 at 7:34 A.M., revealed a nursing assistant book that
contained the shower schedules. The book contained a note that revealed If there is no hot water on station
two please use the station one shower room. The note was not dated.
Interviews with Resident #25, #30, #33 and #35 on 05/10/23 between 10:45 A.M. and 11:10 A.M. confirmed
they have been having issues with lack of hot water several times in the past month. The residents revealed
they have sinks located in their rooms and the water was too cold. The residents revealed the shower room
frequently does not have hot water and this was ongoing issue over the last several weeks.
Interview with the Facility Plumber #500 on 05/10/23 at 9:41 A.M. confirmed he was currently working on
the hot water system in the facility and was here last Friday. Facility Plumber #500 confirmed upon arriving
the hot water on one side of the building was not hot enough. Facility Plumber #500 confirmed the facility
recently installed a larger mixing valve as the old one was not large enough. Facility Plumber #500 stated
he was at the facility to calibrate the system that day (05/20/23).
Interview with Chief Operating Officer (CEO) #600 on 05/10/23 at 9:57 A.M. revealed at this time they could
not locate any water temperature log checks for the month of May 2023, as the facility's maintenance
director was on vacation.
Review of the facility's undated bath/shower water temperature monitoring policy revealed the purpose was
to establish procedures to ensure the protection of individuals from hot water while bathing/showering. Hot
water used for bath hand shower shall be between 110-115 degrees F. Residents shall receive the needed
supports and supervision during bathing/showering that will ensure their protection from hot water injuries.
Hot water temperatures shall be in the range of 110-115 degrees F and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365118
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365118
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jag Healthcare Mansfield
50 Blymyer Avenue
Mansfield, OH 44903
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
water temperatures shall be measured and documented by maintenance.
Level of Harm - Minimal harm
or potential for actual harm
This deficiency represents non-compliance investigated under Complaint Number OH00142307.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365118
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the May 10, 2023 survey of Jag Healthcare Mansfield?
This was a inspection survey of Jag Healthcare Mansfield on May 10, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Jag Healthcare Mansfield on May 10, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.