Oak Grove Manor

1670 Crider Rd · Mansfield, OH · 44903 · 4195896222

75 certified beds For profit - Limited Liability company Chain: Lionstone Care

Why this verdict

  • Inspection record is far worse than the national median (deficiency count and severity).
  • Inspection results have improved across recent cycles.

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Red flags

1 immediate-jeopardy citation in prior inspection cycles

Serious past findings — check whether the underlying problems were fixed and stayed fixed.

70% of nursing staff left within a year

High turnover disrupts continuity of care; the national median is 45%.

Score breakdown

Inspection record 30% of score 34
Serious harm & abuse 20% 88
Staffing 20% 55
Federal penalties 15% 74
Trend 10% 87
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5

Total nurse hours / resident-day3.303.48 min · 4.1 strong
RN hours / resident-day0.540.55–0.75
Weekend hours / resident-day2.76≈ weekday level
Nursing turnover / year70%median 45%
Fines (3-yr window)1 · $15,593

Inspection citations (71 in the current record)

  • Potential for harm · D September 25, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected November 17, 2025 · Quality of Life and Care

  • Potential for harm · F September 25, 2025 · found via complaint

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Corrected November 17, 2025 · Nutrition and Dietary

  • Potential for harm · D July 1, 2025

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    Corrected July 25, 2025 · Resident Rights

  • Potential for harm · D July 1, 2025

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected July 25, 2025 · Quality of Life and Care

  • Potential for harm · D July 1, 2025

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

    Corrected July 25, 2025 · Nursing and Physician Services

  • Potential for harm · D July 1, 2025

    Ensure medication error rates are not 5 percent or greater.

    Corrected July 25, 2025 · Pharmacy Service

  • Potential for harm · D July 1, 2025

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

    Corrected July 25, 2025 · Nutrition and Dietary

  • Potential for harm · F July 1, 2025

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected July 25, 2025 · Nutrition and Dietary

  • Potential for harm · E July 1, 2025

    Provide and implement an infection prevention and control program.

    Corrected July 25, 2025 · Infection Control

  • Potential for harm · F July 1, 2025

    Have policies on smoking.

    Corrected July 25, 2025 · Environmental

  • No harm found · B July 1, 2025

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Corrected July 25, 2025 · Resident Rights

  • No harm found · C July 1, 2025

    Observe each nurse aide's job performance and give regular training.

    Corrected July 25, 2025 · Nursing and Physician Services

  • No harm found · C July 1, 2025

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

    Corrected July 25, 2025 · Nursing and Physician Services

  • Potential for harm · D December 23, 2024 · found via complaint

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected December 27, 2024 · Resident Rights

  • Potential for harm · D December 23, 2024 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected December 27, 2024 · Quality of Life and Care

  • Potential for harm · D October 29, 2024 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected November 22, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · F October 29, 2024 · found via complaint

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected November 22, 2024 · Nutrition and Dietary

  • Potential for harm · F October 29, 2024 · found via complaint

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    Corrected November 22, 2024 · Environmental

  • Potential for harm · D July 31, 2024 · found via complaint

    Ensure that residents are free from significant medication errors.

    Corrected August 22, 2024 · Pharmacy Service

  • Potential for harm · F July 31, 2024 · found via complaint

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Corrected August 22, 2024 · Nutrition and Dietary

  • Potential for harm · D July 31, 2024 · found via complaint

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

    Corrected August 22, 2024 · Nutrition and Dietary

  • Potential for harm · D July 31, 2024 · found via complaint

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

    Corrected August 22, 2024 · Nutrition and Dietary

  • Potential for harm · F May 16, 2024

    Keep residents' personal and medical records private and confidential.

    Corrected June 7, 2024 · Resident Rights

  • Potential for harm · D May 16, 2024

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected June 7, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · F May 16, 2024

    Dispose of garbage and refuse properly.

    Corrected June 7, 2024 · Nutrition and Dietary

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

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

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 365837 · certified since May 6, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.