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
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, advanced age, eczema, psoriasis, and incontinence.
Interventions included padding and protecting skin as needed and pressure reduction devices if ordered.
Observations on 08/25/24 at 11:20 A.M., 08/26/24 at 1:34 P.M., and 08/27/24 at 9:59 A.M. revealed
Resident #55 was lying in bed with her heels lying directly on the mattress. The boots were not in place and
were lying on the floor near the foot and partially underneath of the resident's bed.
During an interview on 08/27/24 at 10:28 A.M., State Tested Nurse Aide (STNA) #353 reported they
provided care for Resident #55 on a regular basis. STNA #353 verified Resident #55 did not have the boots
in place while lying in bed. STNA #353 reported the resident never wore the boots while in bed during the
day.
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:
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
08/28/2024
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 - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
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 standing Hoyer lift or the ceiling
Hoyer lift, you only need one staff member to transfer residents. STNA #346 verified she transferred
Resident #41 with the standing Hoyer lift by herself.
Interview on 08/28/24 at 4:29 P.M. with the Director of Nursing (DON) verified when transferring a resident
with a standing Hoyer, staff always need two staff members and when using the ceiling Hoyer lift, you can
use one or two staff members.
Review of the facility policy titled Sit to Stand/Hoyer Lift Usage Policy, dated 08/22/23 revealed operate the
lift according to the manufacture's instructions, with one staff member operating the lift and another
supporting the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365945
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
365945
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2024
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**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 dated 07/17/24 revealed Resident #168 was at a fall risk and had seizures.
Interventions included a bilateral half size bed rail.
Review of the physician orders dated August 2024 revealed an order for padded bilateral half size bed rails
to the bed at all times.
Observation on 08/26/24 at 9:17 A.M. revealed Resident #168 was lying in bed. Resident #168's bed had
padded metal bed rails on both sides of the bed and both rails were in the raised position. Interview at this
time with Resident #168 stated she was afraid of falling out of the bed and needed the bed rails.
Interview on 08/29/24 at 2:30 P.M. with MDS Nurse #331 verified there was no assessment for the use of
side/assist/bed rails for Resident #168. MDS Nurse #331 stated she just started auditing assessments for
bed rails and did not get to Resident #168.
Review of the facility policy titled Bedrails dated 02/25/20 revealed when a bed or side rail is issued, the
facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the
following elements. Assessing the resident for risk of entrapment from bed rails prior to installation. Review
the risks and benefits of bed rails with the resident or resident representative and obtain informed consent
prior to installation. Follow the manufactures' recommendations and specifications for installing and
maintaining bed rails.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365945
If continuation sheet
Page 3 of 3
