Crystal Care Center of Mansfie

In the surveyor’s words

From the most serious findings on record at Crystal Care Center of Mansfie, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jun 30, 2026

  Based on observations, medical record review, review of infection control documents, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure resident infections were adequately tracked for potential trends, failed to ensure residents who required Enhanced Barrier Precautions (EBP) had signage in place to including instructions for use of specific personal protection equipment (PPE), failed to ensure staff wore PPE during high-contact resident care activities with residents in EBP, and failed to ensure indwelling catheters were stored appropriately. This affected Residents #1, #6, and #49 and had the potential to affect all 60 residents residing in the facility. Findings include: 1. […]

• No harm, potential for more than minimal, patternF570May 6, 2022

  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. […]

• No harm, potential for more than minimal, patternF689May 6, 2022

  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. […]

• No harm, potential for more than minimal, isolatedF677Jun 30, 2026

  Based on medical record review, staff interview, observation and policy review, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received adequate nail care and personal hygiene assistance. This affected two residents (#5 and #43) of three residents reviewed for ADL care. The facility census was 60. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 04/21/20. Diagnoses included anxiety disorder, diabetes mellitus (DM), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition and was dependent on staff with personal hygiene. […]

• No harm, potential for more than minimal, isolatedF761Jun 30, 2026

  Based on observation, record review, policy review, and staff interview, the facility failed to ensure insulin medications were labeled appropriately with a date when opened and resident's names were on the medication, and medications were not left at a resident's bedside. This affected two of six medication carts observed for medication storage and the facility identified there were six medication carts in the facility. This affected Residents #32, #57, and #64. The census was 60. Findings Include: 1. Observation on 06/29/26 at 7:41 A.M. of the 100-Hall A medication cart revealed an insulin Novolin R solution multi-dose vial 100 unit per milliliter (ml) with a dispense date from the pharmacy on 05/30/25 was not dated when opened for Resident #57. […]