Inspection·May 6, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 for wounds. Review of the policy titled, Resident Assessment Instrument dated 10/01/10, revealed the Resident Assessment Instrument correctly and effectively help provide appropriate care. It helps nursing home staff gather definitive information on the residents strengths and needs which must be addressed in an individual care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 2 of 12 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 05/06/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 01/17/22. Diagnoses for Resident #19 included muscle weakness and displaced right hip fracture on 01/14/22, requiring surgery. Review of the care plan initiated 01/04/17, revealed the resident had the potential for impairment to skin integrity. Interventions include to provide a pressure reduction mattress and an egg crate overlay to the bed. There were no specific interventions listed for Resident #19's heels. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had recent surgery with repair of a fracture. Resident #19 was extensive assistance of one staff for bed mobility and had no pressure ulcers. Resident #19 was assessed as being at risk for the development of pressure ulcers. Record review of the form titled Pressure Injury Skin Grid, dated 01/30/22, revealed Resident #19 obtained an unstageable wound to the right heel. The facility added pressure reducing boots on 01/30/22, after the wound developed. Review of the skin grid dated 04/27/22, revealed the resident continued to have an unstageable pressure ulcer to the right heel with eschar present. Record review of the care plan revealed a care plan was initiated for alteration in skin integrity, deep tissue injury to the right heel on 03/03/22. Interview on 05/04/22 at 09:54 A.M., with MDS Nurse, LPN #20, verified there was no care plan for the heels until 03/03/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 3 of 12 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 05/06/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 supervision and set-up help by staff to eat. Observation on 05/03/22 at 11:54 A.M., revealed Resident #213 was lying in bed. The head of the bed was slightly raised. Residents right leg was propped up on a pillow. Resident #213's body had slightly slid down in bed. State Tested Nursing Assistant (STNA) #86 was passing lunch trays and entered Resident #213's room with the lunch tray. STNA #86 placed Resident #213's bed side table over the residents lap then sat her lunch tray on the bed side table. STNA #86 then left the room. Observation revealed the position of the bed side table was at Resident #213's eye level and the head of the bed was only slightly (approximately 20 to 30 degrees) elevated. Resident #213 reached up feeling the tray for her glass of juice. Resident then moved the juice toward her mouth using her tongue to feel for the edge of the glass to not spill the juice on her. Resident #213 was not able to take a drink without spilling the juice and sat the glass back on the tray. Interview on 05/03/22 at 11:56 A.M., with Resident #213 confirmed she was unable to drink the juice without spilling it and was unable to see the food on top of the tray due to her position in bed. Resident #213 confirmed it was difficult to eat and staff did not offer or attempt to reposition her prior to leaving the lunch tray. Resident #213 revealed she did not ask to be repositioned because the staff were busy and she did not want to burden them. Observation and interview on 05/03/22 at 11:58 A.M., with Licensed Practical Nurse (LPN) #56 confirmed Resident #213's head of bed was in a lowered position, the resident's body had scooted down in bed and the resident was unable to see the food on top of her lunch tray to safely eat. Interview on 05/03/22 at 11:59 A.M., with STNA #86 confirmed she served Resident #213's lunch tray and did not position resident to be able to safely see and eat her food. STNA #86 stated, I don't know why I didn't reposition her, I just didn't. STNA #86 confirmed staff were available to assist with repositioning. Observation on 05/04/22 at 4:51 P.M., revealed Resident #213 was lying in bed. The head of the bed was slightly raised. Residents right leg was propped up on a pillow. Resident #213's body had slightly slid down in bed. STNA #94 was passing dinner trays and entered Resident #213's room with the dinner tray. STNA #94 placed Resident #213's bed side table over the residents lap then sat her dinner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 4 of 12 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 05/06/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tray on the bed side table. STNA #94 then left the room. Observation revealed the position of the bed side table was at Resident #213's eye level and the head of the bed was only slightly (approximately 20 to 30 degrees) elevated. Resident was unable to see the food in the dishes on top the tray. Observation of dinner tray revealed tomato soup and a sandwich was served. Observation revealed resident was reaching up with the spoon to the bowl and as she brought the spoon back to her moth, the soup was spilling onto her gown from the spoon. Interview on 05/04/22 at 4:52 P.M. with Resident #213 verified she was unable to see the food on her tray and it was difficult to eat. Resident stated, I don't know why they don't put me up more, they will if i ask but i don't always ask. I don't want to bother them, they are busy. Observation and interview on 05/04/22 at 04:55 P.M., with Registered Nurse (RN) #51 verified Resident #213's position in bed while trying to eat and had food spilled on her gown. Resident #213 stated to RN #51, It's not feasible. Interview on 05/04/22 at 5:01 P.M. ,with STNA #94 confirmed she delivered the dinner tray and did not reposition Resident#213 for her meal. STNA #94 stated, I didn't realize. STNA #94 confirmed staff were available to assist with repositioning a resident. Review of the undated policy titled, Positioning During Eating revealed residents were to be sitting up straight or slightly forward with head upright during meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 5 of 12 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 05/06/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **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 Resident #31's ROM of the bilateral upper extremities. Review of the OT discharge recommendations, dated 03/03/22, revealed the resident was recommended to have a palm protector to the left hand and Comfy Grip hand orthosis to the right hand. Review of the restorative plan of care dated 04/01/22 through 05/03/22, revealed the resident would participate in ROM exercises for her bilateral upper extremities daily, and would participate with splinting of bilateral hands after ROM exercises for between two and three hours daily. Review of the corresponding restorative documentation, dated 04/01/22 through 05/03/22, revealed restorative services were provided to Resident #31 on 04/09/22, 04/10/22, 04/19/22, 04/20/22, and 04/21/22. Restorative services including ROM and splinting were not documented as provided for the other 28 days within this time period. Observation on 05/02/22 at 11:24 A.M., revealed both the left and right hands of Resident #31 were contracted. Resident #31 was unable to fully open either hand. At no time during the annual survey on 05/02/22, 05/03/22, or 05/04/22 over multiple observations, was any type of splint or orthotic device observed in place for Resident #31. Interview on 05/03/22 at 4:16 P.M., with Licensed Practical Nurse (LPN) #102 verified Resident #31 was only documented as receiving restorative services for five out of 33 days. LPN #102 reported State Tested Nurse Aides (STNA) were responsible for providing restorative services such as ROM and application of splints or other orthotic devices. Interview on 05/04/22 at 1:41 P.M., with STNA #50, revealed she was frequently assigned to work with Resident #31 and was unaware of any orthotic devices or splints in place for either of the resident's hands. Interview on 05/04/22 at 2:00 P.M., with Resident #31's husband, revealed Resident #31's husband was typically at the facility on a daily basis from 11:00 A.M. to 6:00 P.M. Resident #31's husband (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 6 of 12 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 05/06/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm reported LPN #102 brought down and placed palm protectors on each of Resident #31's hands on 05/03/22 and he had never seen them prior to then. Review of the policy titled, Restorative Nursing Program, dated 12/06/17, revealed restorative programs would be documented on the facility designated restorative care form. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 7 of 12 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 05/06/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 identified the security bracelet was discontinued on [DATE]. Observation on [DATE] at 4:32 P.M., of Resident #12 was sitting in her wheelchair in the television room. The back section of the chair was observed with a security bracelet bracelet device attached to the back of the chair. Observation of the device security bracelet bracelet identified it had expired in [DATE]. Observation and interview with the facility Assistant Director of Nursing (ADON) #105 on [DATE] at 4:52 P.M., verified Resident #12's security bracelet located on the wheelchair is expired. The interview additionally verified the testing book located at the nursing station for all residents with a device does not list the expiration dates for any of seven devices being used currently for Resident Resident #9, #20, #22, #28, #33, #34,#113 . ADON #105 stated the testing logs are completed by the night shift licensed nursing staff and are tested every night. ADON #105 stated the expiration date for each device should be listed on the testing log, to ensure devices are changed out when they expire. Interview on [DATE] at 8:34 A.M. ,with the Director of Nursing (DON) verified the facility has four extra security bracelets located in a box to be used when needed. The DON stated these four have not been tested and logged. Review of the Secure Care (security bracelet) manufactures instruction dated [DATE], revealed to ensure proper operation of the transmitter it must be upright or vertical position on the ankle. The policy also identified a documented test of each ankle device must be made daily including transmitters not in use. The instructions revealed the actual expiration date is the last day of the month engraved on the transmitter. 2. Review of Resident #112's medical record revealed an admission date of [DATE], with medical diagnoses including: chronic pancreatitis, muscle weakness, aphasia and dementia. Review of the [DATE] physician's orders identified on [DATE] a security bracelet was placed on the left ankle. Review of Resident #112's security bracelet, nightly Wander-guard (security bracelet) Prevention form identified no evidence of the date the bracelet expires. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 8 of 12 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 05/06/2022 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 Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #21's medical record revealed an admission date of [DATE],with medical diagnosis including; Sepsis, urinary tract infections, depression, dementia, bipolar disorder, and bilateral femur fractures. Review of the quarterly assessment dated [DATE] identified Resident #21 was cognitively intact and required extensive assistance of one person for bed mobility. Resident #21 was identified to have fallen from the bedside on [DATE] and fractured both legs. Residents Affected - Some Review of Resident #21's written plan of care for fall prevention included interventions of mat to the bedside, winged pressure reduction mattress and voice activated alarm to bed. Review of the [DATE] physician orders identified winged mattress. Observation on [DATE] at 7:00 A.M., of Resident #21 was observed in bed revealed there was no mat next to the bed or winged mattress on the bed. Observation on [DATE] at 2:43 P.M., of Resident #21 reveled upon returning from Dialysis and was placed in bed. There was no fall mat located next to the bed, the voice alarm was sitting on the bedside stand unattached and the mattress was not winged type after the resident was placed in bed. Observation and interview on [DATE] at 3:05 P.M., with Licensed Practical Nurse (LPN #102) verified Resident #21's voice alarm was laying on the bedside table unattached, no winged mattress was on the bed and the fall mat was placed at the end of the bed, instead of the bedside. LPN #102 verified Resident #21 fall interventions were not in place. 4. Review of Resident #20's medical record revealed an admission on [DATE], with medical diagnosis including gastro-esophageal reflux disease, hyperlipidemia, osteoarthritis, ataxia, diabetes mellitus type 2, bipolar disorder, and hypertension. The physician orders identified Resident #20 to have a wander-guard placed on her right ankle starting on [DATE]. Observations of Resident #20's security bracelet to be present on her right ankle in the up-right position from [DATE] through [DATE]. Observation of the device identified with an expiration date of [DATE]. Interview and observation on [DATE] at 8:32 A.M., with RN #51 verified Resident #20's security bracelet is tested every night by licensed nurse and confirmed the expiration date to be in [DATE]. However, the expiration date was not present on the testing log book. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 9 of 12 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 05/06/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 changes. Review of the Nutritional assessment dated [DATE], completed by Registered Dietitian (RD) #115, revealed the resident received a house supplement two times a day and consumes 25 % of meal intakes. A Readmitting Nutrition Assessment was completed. Resident #19 had a diagnosis of a hip fracture with surgical repair. Resident #19 was noted with poor meal intakes/refusals since return. A mechanical soft diet will continue with a house supplements two times a day. Resident #19 was accepting the house supplements per nursing staff. Potential for significant weight changes with fluid shifts, will monitor effects on appetite. Will recommend increasing the house supplement to three times a day at this time to increase calorie/protein/fluid intakes and will continue to monitor intakes, weights and laboratory tests for need of additional interventions. There was no weight listed for the resident. Record review of the physician's orders revealed on 01/24/22, a new order was completed by RD #115 to increase the house supplement to three times a day. Record review of the medication administration record (MAR) for 01/24/22 through 01/31/22, revealed Resident #19 received the house supplement three times a day. Review of the MAR for February 2022 and March 2022 revealed no record of a house supplement being offered. Review of the MAR for April 2022 revealed on 04/26/22, health supplement three times a day was added to the MAR. The health supplement three times a day was also added to the MAR for May 2022. Interview on 05/04/22 at 2:30 P.M., with the Director of Nursing (DON) confirmed the house supplement was not on the MAR for February and March 2022 and was not restarted until 04/26/22. The DON revealed this was a transcription error and confirmed the house supplement was not given during that period. Interview on 05/04/22 at 2:57 P.M., with RD #115 revealed Resident #19 received and would accept the house supplements when offered. RD #115 revealed she was not made aware the resident had not received the supplements as ordered. 2. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 10 of 12 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 05/06/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's nutritional assessment dated [DATE] identified the resident should be getting a regular diet with large meat portions, super-cereal in the morning and pudding every day. Review of Resident #21's diet card (used by kitchen to prepare meals) identified no evidence of super-cereal every morning. Residents Affected - Few Review of Resident #21's May 2022, physician orders revealed an order for regular high protein diet. The orders did not list any supplements including the super-cereal and or pudding. Observation of Resident #21's breakfast meals occurred on 05/03/22 and 05/05/22 with no super-cereal observed provided for Resident #21. Interview on 05/05/22 at 8:02 A.M., with the DON verified Resident #21 did not received super cereal and the dietary recommendations and physician orders do not match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 11 of 12 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 05/06/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 regards to nutritional issues. Observation on 05/03/22 at 2:28 P.M., revealed Resident #21 had returned to the facility from Dialysis. Resident #21 identified she does not get any lunch on her Dialysis days (Tuesday, Thursday and Saturdays). Resident #21 stated no one is allowed to have any food at the dialysis center and therefore nothing is sent with her to the center. Resident #21 stated she was very hungry at this time. Interview on 05/03/22 at 3:05 P.M., with Licensed Practical Nurse (LPN) #102 verified the facility does not have anything specific scheduled for Resident #21 to receive food just prior to leaving or returning from dialysis. LPN #102 verified the facility needs to do something for Resident #21 on those days. Interview via telephone, on 05/03/22 at 3:19 P.M., with the Dialysis Center Representative #400 verified the center does not allow for food to be brought in and this will not be changing this practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365945 If continuation sheet Page 12 of 12