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Nursing HomeMedicaid Investigative

Oak Grove Manor

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1670 Crider Rd, Mansfield, OH 4490375 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.4/5

based on 56 Google reviews

5
4
3
2
1
Oak Grove Manor Nursing Home in Mansfield, OH — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (13 vs median 8.0)
  • High staff turnover (76%)
  • High RN turnover (90%)

Bottom 25% in OH · Below recommended RN staffing · Very high staff turnover · Worst in LIONSTONE CARE chain · $15,593 in fines

Source: Medicare data

What this means for your family

While the rehabilitation therapy team is frequently praised for helping residents recover, the facility suffers from significant, recurring reports of neglect, including slow response times and hygiene issues. If you consider this facility, we strongly recommend conducting an unannounced visit during a weekend or evening shift to observe staffing levels and response times firsthand.

Google Reviews

Google Reviews

56 reviews on Google
Oak Grove Manor receives highly polarized feedback, with some families praising the rehabilitation therapy team and individual staff members, while others report severe neglect and hygiene concerns. While some reviewers highlight successful recoveries and compassionate care, a significant number of reports describe long wait times for call lights, poor facility cleanliness, and unprofessional behavior from nursing and administrative staff. Families should be aware of these inconsistencies and perform a thorough in-person visit before placement.

Quality Themes

Tap a score for details
Food3.0Staff4.0Clean2.0Activities6.0MedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Highly effective rehabilitation therapy team
  • Some staff members described as caring and attentive
  • Successful short-term recovery outcomes

Concerns

  • Slow response times to call lights (mentioned by 5 reviewers)
  • Poor hygiene and lack of assistance with showering/clothing changes (mentioned by 4 reviewers)
  • Understaffing leading to neglect (mentioned by 4 reviewers)
  • Unprofessional or rude staff behavior (mentioned by 4 reviewers)
  • Poor food quality and difficulty with meal requests (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(3)'21(4)'23(6)'25(11)

Distribution · 58 analyzed

5
31
4
4
3
1
2
2
1
20

How They Respond to Reviews

80%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1Given the recent feedback regarding response times to call lights, what specific protocols do you have in place to ensure residents receive timely assistance?
  • 2I noticed the facility has a strong reputation for rehabilitation outcomes; how do you ensure that same level of dedicated attention carries over into daily personal care like hygiene and dressing assistance?
  • 3Could you walk me through your current staffing model and how you ensure there is adequate coverage to meet the needs of all 75 residents throughout the day and night?
  • 4I see that you actively respond to feedback online; how do you use that family input to make tangible improvements to the dining experience and food quality?
  • 5What steps are being taken to address the recent health inspection findings to ensure the facility meets the highest standards of safety and cleanliness for your residents?
  • 6How do you foster a positive and professional environment for your staff to ensure that every interaction with a resident is supportive and respectful?

Personalized based on this facility's data


Key Review Excerpts

The physical therapists are amazing! But!!! 90% of staff should NOT be there.

Visitor · 2023☆☆☆☆

Neglectful of patients. My friend was admitted for rehab & didn't get a clean gown for 3 days, then 6 more days before next gowm. No bath for 10 days, I had to ask, they hadn't put her on the shower schedule!!!

Friend of resident · 2022☆☆☆☆

The facility itself looks a little worn down and old, there definitely could be some improvement with the infrastructure, but the nurses and aids are what truly redeem this place.

Grandchild of resident · 2023★★★★
Source: 56 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.54hrs
73%
Registered nurses for medical care
Total Nursing
3.30hrs
81%
All nurses + aides combined
Staff Turnover
70%
Lower is better (< 30% = good)
RN Turnover
77%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

3

measures

Worse Than Avg

8

measures

Mixed Results

6

measures

Long-Stay Residents
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility36.3%
Worse than Avg
Here
36.3%
US
93.4%
OH
92.6%
Richland
90.6%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility82.4%
Worse than Avg
Here
82.4%
US
95.5%
OH
94.5%
Richland
93.3%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility13.5%
Better than Avg
Here
13.5%
US
19.5%
OH
25.4%
Richland
19.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility27.9%
Worse than Avg
Here
27.9%
US
19.4%
OH
21.6%
Richland
17.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility19.6%
Mixed vs Avgs
Here
19.6%
US
12.1%
OH
28.2%
Richland
14.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.3%
Mixed vs Avgs
Here
7.3%
US
15.3%
OH
6.9%
Richland
13.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility11.4%
Worse than Avg
Here
11.4%
US
79.7%
OH
75.6%
Richland
77.3%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility27.8%
Worse than Avg
Here
27.8%
US
81.8%
OH
78.4%
Richland
79.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.2%
Worse than Avg
Here
2.2%
US
1.6%
OH
1.2%
Richland
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

13deficiencies
1penalties
Above state avg (10.1)
34 complaint-triggered
$15,593 in fines

Oak Grove Manor shows concerning patterns of recurring issues with families filing multiple complaint reports over the past three years. The most persistent problems involve food safety and preparation, medication management, and infection control, with many issues repeating across multiple surveys. While all deficiencies appear corrected, the frequency of complaints and repeated violations in critical care areas suggest ongoing operational challenges that warrant careful evaluation during any visit.

Sep 25, 2025Complaint
2
0804Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jul 1, 2025Routine
14
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0926Potential for harm · WidespreadCorrected

Environmental Deficiencies

Have policies on smoking.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0800Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0730Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

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

0947Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

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

0582Minimal · PatternCorrected

Resident Rights Deficiencies

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

Dec 23, 2024Complaint
2
0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Oct 29, 2024Complaint
3
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0925Potential for harm · WidespreadCorrected

Environmental Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Jul 31, 2024Complaint
4
0804Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0805Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

May 16, 2024Routine
14
0583Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0814Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0131Potential for harm · WidespreadCorrected

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

0211Potential for harm · WidespreadCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0511Potential for harm · WidespreadCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0753Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0923Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Federal Penalties

Fine

Dec 27, 2023

$15,593

Ownership & Operations

Who Operates This Facility

Owner / Operator

Oak Grove Manor

Organization Type

for profit

Chain Affiliation

Chain Name

Lionstone Care

Chain Size

22 facilities nationwide

Chain avg rating: 2.6/5 · Rank 22 of 22 (Worst)

Ownership & Management

Owners

Lionstone Hz Opco Holdings LLC

Owner · Organization

100%

Kazarnovsky, Solomon

Owner (parent company)

50%

Stein, Abba

Owner (parent company)

50%

Key personnel

Cusner, AdamOfficer / DirectorDegyansky, JeffreyOfficer / DirectorGoldish, EliezerOfficer / DirectorKazarnovsky, SolomonOfficer / DirectorStein, AbbaOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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