Crawford Manor Healthcare Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, self-reported incident (SRI) review, review of a witness statement, and staff interview, the facility failed to ensure a resident was provided adequate assistance with activities of daily living (ADLs) to prevent an avoidable fall with injury. Actual harm occurred to Resident #28 on 03/19/26 when a nurse aide assisted the resident with bed mobility without another staff member present and Resident #28 fell to the floor. Resident #28 had care plan interventions and therapy recommendations in place at the time of the fall indicating two staff members were to assist the resident with ADLs and bed mobility. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a self-reported incident (SRI), review of a witness statement, staff interview, and policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse. This affected one (Resident #21) of three residents reviewed for abuse. The facility census was 35. Findings Include:Review of the medical record for Resident #16 revealed the resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, hypertension, history of cerebral infarction, altered mental status, muscle weakness, history of falls, and adjustment disorder with mixed anxiety and depressed mood. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, resident, family, and staff interviews, review of the National Weather Service forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision and intervention to prevent Resident #33, who had a history of wandering, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, or death when Resident #33 was seen (by camera footage) on 12/04/24 at 6:47 P.M. leaving the facility on foot with his rollator walker. The resident was missing from the facility for approximately one hour and 45 minutes without staff knowledge. The resident's whereabouts remained unknown until 12/05/24 at 12:07 A.M. [...]

Inspectors wroteBased on staff interview, medical record review, review of facility investigations, and review of the facility policy, the facility failed to ensure a resident was free from verbal abuse. This affected one (Resident #35) of three residents reviewed for abuse. The facility census was 33.

Inspectors wroteBased on staff interview, medical record review, review of facility investigations, and review of the facility policy, the facility failed to thoroughly investigate an allegation of verbal abuse. This affected one (Resident #35) of four residents reviewed for abuse. The facility census was 33.

Inspectors wroteBased on medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors of 31 opportunities for an error rate of 6.45%. This affected one (Residents #32) of four residents reviewed for medication administration. The facility census was 33 residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to store medication per the manufacturers recommendations. This affected one (Resident #32) of four residents reviewed for medication administration. The facility census was 33.

Inspectors wroteBased on observation, staff and resident interviews, and review of the facility policy, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect 40 residents who received meals in the facility. The facility identified Residents #30 and #32 as receiving no food from the kitchen. The facility census was 42.

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure the kitchen was clean and sanitary, food items were appropriately dated, and coffee was covered as required when walking down the third-floor hallways. This had the potential to affect 40 residents who received food from the kitchen. The facility identified two residents (#30 and #32) as receiving no food from the kitchen. The facility census was 42.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10's had a sanitary room free of bed bugs. This affected one resident (Resident #10) out of three residents reviewed for bed bugs.

Inspectors wroteBased on interview, record review, review of the facility policy, review of the facility fall investigation, and review of the Emergency Medical Services report the facility failed to ensure care and services and individualized care planned interventions for Resident #38 were implemented resulting in a fall. This affected one resident (Resident #38) out of three residents reviewed for falls. The facility census was 37.

Inspectors wroteBased on observation, staff interview, interview with contracted pest control staff, and review of the facility policy the facility failed to ensure food storage areas were free from pests. This had the potential to affect all residents except for Resident #5 identified by the facility as receiving no food from the kitchen. The facility census was 39.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to prevent unauthorized videos from being taken and shared on social media by a staff member of Resident #20 and Resident #23. This affected two residents of three residents reviewed for abuse.

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure care planning conferences were conducted at least quarterly. This affected two (Residents #6 and #27) of three reviewed for care planning. The facility census was 39.

Inspectors wroteBased on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to complete assessments and care plans regarding resident smoking. This affected one (Resident #42) of three residents reviewed for smoking. The facility census was 39.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to provide suprapubic catheter site care for one (Resident #5) of one resident reviewed for catheter care. The facility census was 39.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were followed up on in a timely manner. This affected three residents (#22, #25, and #26) of five residents reviewed for unnecessary medications. The facility census was 39.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure weights were documented accurately for Resident #41. This affected one resident (#41) of three residents reviewed for nutrition. The facility census was 39.

Inspectors wroteBased on interview, record review, review of the facility policy and Centers for Disease Control and Prevention (CDC) guidelines the facility field to ensure pneumococcal vaccinations were offered and provided as recommended by the CDC. This affected three residents (#11, #21, and #26) of five residents reviewed for pneumococcal vaccinations. The facility census was 39.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of the facility Cardiopulmonary Resuscitation (CPR) policy and interviews, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #37, who was found unresponsive, without a pulse/heartbeat and identified as a full code status. This resulted in Immediate Jeopardy that was actual harm on [DATE] when Resident #37 did not receive CPR, EMS were not contacted for medical services and the resident subsequently expired. This affected one resident (#37) of two residents reviewed for death in the facility. The facility census was 34 residents. On [DATE] at 10:07 P.M. [...]

Inspectors wroteBased on observation, test tray, interview and policy review, the facility failed to serve food that was appealing, palatable and served at an appetizing temperature. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview and review of cleaning schedules, the facility failed to ensure food surfaces in the main kitchen were clean and sanitary. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to timely report and coordinate with the Local Health Department (LHD) regarding employee and resident COVID-19 positive cases to prevent further spread of COVID-19 within the facility. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview, observation, record review and policy review the facility failed to ensure staff properly wore appropriate personal protective equipment (PPE) including eye protection when in the facility as the county positivity rate was at 36.4 percent indicating high transmission rate, visitors were properly screened for sign and symptoms of COVID-19 prior to entrance into the facility, residents were provided with clean masks to wear, staff performed proper hand hygiene during meal service, staff were properly screened for tuberculosis or administered tuberculin skin test per facility protocol, and the facility had a Legionella prevention - water management policy and procedure, a legionella risk assessment, and a water management program to reduce risk, growth, and spread of legionella. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview, observation, record review and policy review, the facility failed to ensure staff were tested per COVID-19 outbreak testing guidelines, staff had COVID-19 competency testing signed off per trainer/ evaluator, and staff wore a gown when they completed COVID-19 testing on residents. This had the potential to affect all 36 residents residing at the facility.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and sanitary living environment and kitchen environment. This had the potential to affect all 36 residents in the facility.

Inspectors wroteBased on medical record review, staff interview and facility bed hold policy review, the facility failed to ensure adequate notification in writing of the discharges to the hospital. This deficient practice affected eleven (Resident's #8, #26, #29, #35, #38, #137, #138, #139, #140, #142 and #143) of eleven residents reviewed for bed hold notification. The facility identified 11 residents who were transferred from the facility in the last five months. The facility census was 36.

Inspectors wroteBased on medical record review, staff interview and facility bed hold policy review, the facility failed to ensure adequate notification of available bed hold days was provided to residents at the time of discharge to the hospital. This deficient practice affected eleven (Resident's #8, #26, #29, #35, #38, #137, #138, #139, #140, #142 and #143) of eleven residents reviewed for bed hold notification. The facility identified 11 residents who were transferred from the facility in the last five months. The facility census was 36.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete comprehensive assessments Minimum Data Set (MDS) 3.0 for five residents: Resident #1 (sections C, D, E and O), Resident #4 (sections C and E), Resident #16 (section C and E), Resident #19 (section C) and Resident #32 (sections F and K) of 29 MDS 3.0's reviewed (Resident's #1, #3, #4, #9, #11, #12, #13, #15, #16, #17, #18, #19, #25, #28, #27, #29, #30, #31, #32, #33, #35, #36, #38, #39, #88, #187, #189, #190 and #191) reflecting the resident's status at the time of the assessment. The facility census was 36.

Inspectors wroteBased on interviews, observations, record and activity calendar review, the facility failed to implement individualized activity program providing stimulation or solace to create opportunities for a meaningful life based on the individual assessment. This affected three (Resident's #17, #18 and #32) of three residents reviewed for activities and four (Resident's #5, #19, #22 and #25) who attended the group meeting. The facility census was 36.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure residents or resident families were notified of positive COVID-19 cases of employees and residents in the facility. This affected six (Resident's #25, #15, #5, #22, #35 and #19) of six residents reviewed for facility notification of positive COVID-19 cases and had the potential to affect all 36 residents residing at the facility.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed the ensure call lights were functioning properly. This affected six (Resident's #4, #13, #15, #19, #31 and #88) of 36 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to consistently implement smoking policies and ensure congruence between the policy, assessment, care plan, and smoking contracts. This affected all nine residents identified as smokers (Resident's #1, #3, #11, #12, #13, #15, #28, #35 and #90) and had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed ensure Resident #32 ate in a dignified manner and failed to provide a privacy cover for Resident #187's indwelling urinary catheter bag. This affected two (Resident's #32 AND #187) reviewed for dignity and of 36 residents observed or interviewed related to dignity. The facility census was 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #88's choice of shower schedule was obtained and preferences honored. This affected one (Resident #88) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36.

Inspectors wroteBased on interview and review of resident accounts, the facility failed to notify the resident/responsible party when the amount reached less than $200.00 than the supplemental security income resource limit. This affected two (Resident's #14 and #33) of five (Resident's #5, #12, #14, #33 and #91) accounts reviewed of 19 accounts managed by the facility. The facility census was 36.

Inspectors wroteBased on interview, record review and policy review, the facility failed to notify Resident #88's first emergency contact following falls and a room change. This affected one (Resident #88) of three family interviews conducted. The facility census was 36.

Inspectors wroteBased on interview, review of Self-Reported Incident (SRI) tracking number (#)196872, record review and policy review, the facility failed to ensure Resident #19 was free from being physically restrained. This affected one (Resident #19) of three (Resident's #5, #19 and #193) reviewed for abuse/SRI's. The facility census was 36.

Inspectors wroteBased on interview, review of the facility Self-Reported Incident (SRI) Form with tracking number (#)196872, review of personnel files, record review and policy review, the facility failed to implement the abuse policy as State Tested Nurse Aide (STNA) #646 failed to report she physically restrained Resident #19. This affected one (Resident #19) of three (Resident's #5, #19 and #193) reviewed for abuse/ SRI's. The facility census was 36.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess Resident #32's activity pursuit using the resident assessment instrument. This affected one (Resident #32) of three (Resident's #17, #18 and #32) reviewed for activities. The facility assessment was 36.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide showers to Resident's #33 and #88 who were dependent on staff for care. This affected two (Resident's #33 and #88) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care for Resident #33. This affected one (Resident #33) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure unsecured medications were not left unattended on Resident #187's bedside table. This affected one (Resident #187) of eight (Resident's #27, #25, #10, #29, #6, #14, #18 and #187) observed for unsecured medications. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure Resident's #4, #25 and #27 were offered and/ or the facility had documentation the resident or resident's responsible party was educated regarding the benefits and potential risks of the influenza and pneumococcal vaccines. This affected three (Resident's #3, #25 and #27) of five (Resident's #4, #15, #25, #27 and #29) reviewed for immunizations. The facility census was 36.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure employee reference checks were completed prior to hire as part of the facility abuse policy to screen new employees. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place through out the medical record for Resident #12. This affected one of one residents reviewed for advanced directives.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive care plans were developed related to substance abuse for Resident #18 and for oxygen level monitoring for Resident #5. This affected two residents of 14 residents whose care plans were reviewed.