F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**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.
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 2
Event ID:
365945
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
365945
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care Center of Mansfie
1159 Wyandotte Ave
Mansfield, OH 44906
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and facility policy review, the facility failed to ensure adequate
supervision for a resident when in the bathroom. This resulted in actual harm when a resident fell in the
bathroom and sustained a fracture of the right clavicle (collarbone). This affected one resident (#63) of two
reviewed for falls. The facility census was 68.
Findings include:
Medical record review revealed Resident #63 was admitted to the facility on [DATE], with diagnoses
including Parkinson's disease, disorders of bone density, difficulty walking, and hemiplegia (paralysis).
Review of Resident #63's care plan dated 03/15/18, revealed the resident was at risk for falls related to
gait/balance problems. Interventions included to not leave the resident in the bathroom unattended.
Review of Resident #63's nurse's note dated 03/06/19 revealed State Tested Nursing Assistant (STNA)
#231 reported to the nurse she had assisted Resident #63 on the toilet and walked away to get toothpaste.
When STNA #231 went back to the bathroom she saw the resident slide off the toilet and landed on her
right shoulder.
Review of Resident #63's fall investigation dated 03/06/19 revealed the resident's fall occurred on 03/06/19
at 7:10 A.M. STNA #231 witnessed the fall. Review of STNA #231's statement revealed Resident #63 had
been on the toilet when she walked away to get toothpaste. When she returned to the bathroom she
witnessed the resident fall off the toilet and hit her right shoulder.
Review of Resident #63's nurse's note dated 03/06/19 revealed the physician had visited the resident after
the fall due to pain in her right arm. The physician ordered an x-ray and the results revealed a fractured
right clavicle. A sling was provided for the resident's right arm and a follow up visit with an orthopedic was
made.
Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
intact cognition. The resident required extensive assistance of one person for transfers and toilet use.
Further review revealed the resident was not steady moving on and off the toilet and had impairment on
one side.
Interview on 05/16/19 at 8:56 A.M., with STNA #231 verified she had left Resident #63 unattended on the
toilet on 03/06/19 and the resident fell off the toilet.
Review of facility policy titled Fall Prevention Program undated revealed the facility will identify patients at
risk for falls and initiate interventions to prevent falls and reduce the risk of injury due to falls.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365945
If continuation sheet
Page 2 of 2
