Ohio ›Mansfield

Oak Grove Manor

1670 Crider Rd, Mansfield, OH 44903 · Richland County · 75 certified beds · avg 72 residents/day · certified since May 6, 1991

Part of chain: LIONSTONE CARE (24 facilities, chain avg rating 2.5★)

1/5
Health inspection rating (on-site)
2
Serious findings on record
$15,593
Fines, last 3 years
3.42
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Feb 6, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Feb 24, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 6, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Feb 24, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (71)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Sep 25, 2025F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Sep 25, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 1, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 1, 2025F · Potential for harm, facility-wideThe facility did not have policies on smoking.
Jul 1, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 1, 2025D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jul 1, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 1, 2025D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jul 1, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jul 1, 2025D · Potential for harm, one-offThe facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs.
Jul 1, 2025C · Minimal risk, facility-wideThe facility did not observe each nurse aide's job performance or provide regular training as required.
Jul 1, 2025C · Minimal risk, facility-wideThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Jul 1, 2025B · Minimal risk, repeatedThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Dec 23, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Dec 23, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 29, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Oct 29, 2024F · Potential for harm, facility-wideThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jul 31, 2024F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Jul 31, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jul 31, 2024D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Jul 31, 2024D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
May 16, 2024F · Potential for harm, facility-wideThe facility did not keep residents' personal and medical information private and confidential.
May 16, 2024F · Potential for harm, facility-wideThe facility did not dispose of garbage and refuse properly.
May 16, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 16, 2024E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint
May 16, 2024E · Potential for harm, repeatedThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. · from a complaint
May 16, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
May 16, 2024D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint
May 16, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 16, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
May 16, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
May 16, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Feb 6, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 6, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Feb 6, 2024F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint
Feb 6, 2024F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Feb 6, 2024E · Potential for harm, repeatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 6, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Feb 6, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Dec 27, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Nov 21, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Nov 21, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 26, 2023D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 1, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Aug 1, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Nov 15, 2022F · Potential for harm, facility-wideThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Nov 15, 2022F · Potential for harm, facility-wideThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 15, 2022F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Nov 15, 2022F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Nov 15, 2022F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 15, 2022E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Nov 15, 2022E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Nov 15, 2022E · Potential for harm, repeatedThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Nov 15, 2022E · Potential for harm, repeatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Nov 15, 2022E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Nov 15, 2022D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Nov 15, 2022D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Nov 15, 2022D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Nov 15, 2022D · Potential for harm, one-offThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Nov 15, 2022D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Nov 15, 2022D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Nov 15, 2022D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs.
Nov 15, 2022D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 11).

YearCitationsSerious (G–L)Worst severity that year
2022250F
202360D
2024272J ▲
2025130F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $15,593.

DateTypeAmount / length
Dec 27, 2023Fine$15,593

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityOhio avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.423.453.95top 42% in Ohio; bottom 32% in the U.S.
Registered Nurse hours0.430.600.69bottom 25% in Ohio; bottom 27% in the U.S.
Weekend total nurse staffing2.883.073.50bottom 44% in Ohio; bottom 24% in the U.S.
Weekend RN hours (not acuity-adjusted)0.230.420.48bottom 13% in Ohio; bottom 17% in the U.S.
Total nursing staff turnover (%)68.148.745.8bottom 9% in Ohio; bottom 7% in the U.S.
RN turnover (%)88.243.942.9bottom 2% in Ohio; bottom 2% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.32, RN 0.42, weekend 2.79. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Kazarnovsky, SolomonIndividual5% or Greater Indirect Ownership Interest50%01/01/2023
Lionstone HZ Opco Holdings LLCOrganization5% or Greater Direct Ownership Interest100%01/01/2023
Stein, AbbaIndividual5% or Greater Indirect Ownership Interest50%01/01/2023
Cusner, AdamIndividualCorporate OfficerNOT APPLICABLE01/27/2025
Cusner, AdamIndividualOperational/Managerial ControlNOT APPLICABLE01/27/2025
Cusner, AdamIndividualADP of the SNFNOT APPLICABLE01/27/2025
Degyansky, JeffreyIndividualCorporate OfficerNOT APPLICABLE01/01/2020
Degyansky, JeffreyIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2023
Degyansky, JeffreyIndividualADP of the SNFNOT APPLICABLE01/01/2023
Goldish, EliezerIndividualCorporate OfficerNOT APPLICABLE10/09/2023
Goldish, EliezerIndividualOperational/Managerial ControlNOT APPLICABLE10/09/2023
Goldish, EliezerIndividualADP of the SNFNOT APPLICABLE10/09/2023
Kazarnovsky, SolomonIndividualCorporate OfficerNOT APPLICABLE01/01/2023
Stein, AbbaIndividualCorporate OfficerNOT APPLICABLE01/01/2023
Stein, AbbaIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
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Crystal Care Center of Ashland10.0 miAshland, OH★☆☆☆☆2/5
Kingston of Ashland10.6 miAshland, OH★★★☆☆2/5
Lexington Court Care Center10.6 miLexington, OH★★★★☆3/5
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Facility data as of CMS processing date 2026-08-01. CCN 365837.