Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
34 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #33 eloped from the facility without staff knowledge, resulting in immediate jeopardy to resident health or safety.
Complaint Details
The complaint investigation substantiated that resident neglect occurred when staff failed to respond appropriately to a door alarm, allowing Resident #33 to leave the facility unnoticed. The resident was found injured after being missing for nearly two hours in severe winter weather. The facility implemented corrective actions and education to prevent recurrence.
Findings
The facility failed to provide adequate supervision and intervention to prevent Resident #33, who had a history of wandering, from leaving the facility unnoticed. The resident was missing for approximately one hour and 45 minutes in severe winter weather conditions and was later found injured. The facility substantiated resident neglect and implemented corrective actions including staff education, door alarm monitoring, and elopement drills.
Deficiencies (1)
Failure to provide adequate supervision and intervention to prevent Resident #33 from eloping from the facility.
Report Facts
Residents reviewed for elopement: 6
Residents identified at risk for elopement: 7
Facility census: 34
Duration resident missing: 105
Temperature range: 21
Temperature range: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #237 | Licensed Practical Nurse | Notified Director of Nursing that Resident #33 was missing and initiated search. |
| Director of Nursing | Director of Nursing (DON) | Notified Administrator and family, involved in corrective actions and education. |
| Administrator | Administrator | Notified of Immediate Jeopardy, led corrective actions and education. |
| LPN #243 | Licensed Practical Nurse | Attempted to obtain vital signs for Resident #33 and reported resident missing. |
| CNA #217 | Certified Nursing Assistant | Rode elevator with Resident #33 and unaware resident did not smoke. |
| RDCS #245 | Regional Director of Clinical Services | Validated door alarms and participated in corrective actions. |
| ADON #240 | Assistant Director of Nursing | Completed updated elopement observations and audits. |
| LPN/MDS #218 | Licensed Practical Nurse/Minimum Data Set Nurse | Educated staff and monitored door alarms. |
| LPN/Charge Nurse #237 | Licensed Practical Nurse/Charge Nurse | Participated in elopement drills and education. |
| LPN/Charge Nurse #207 | Licensed Practical Nurse/Charge Nurse | Completed resident education related to elopement risk. |
| LPN/Charge Nurse #243 | Licensed Practical Nurse/Charge Nurse | Completed resident education related to elopement risk. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of verbal abuse and medication errors at Crawford Manor Healthcare Center.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00158631. The complaint involved allegations of verbal abuse by LPN #242 towards Resident #35 and medication administration errors affecting Resident #32. The investigation found the verbal abuse incident unsubstantiated but identified failures in investigation and medication administration.
Findings
The facility failed to ensure a resident was free from verbal abuse and failed to thoroughly investigate the allegation of verbal abuse. Additionally, the facility had medication errors exceeding the 5% threshold and failed to store medications according to manufacturer guidelines.
Deficiencies (4)
Failed to protect a resident from verbal abuse by a Licensed Practical Nurse (LPN #242).
Failed to respond appropriately to an allegation of verbal abuse and failed to thoroughly investigate the incident.
Medication error rate exceeded 5% with two errors out of 31 opportunities, including incorrect medication dose and missed medication administration.
Failed to store medication (arformoterol solution) per manufacturer's recommendations, including improper storage temperature and packaging.
Report Facts
Facility census: 33
Medication error rate: 6.45
Medication errors: 2
Medication opportunities: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #242 | Licensed Practical Nurse | Named in verbal abuse allegation and investigation. |
| Mobile Director of Nursing #246 | Mobile Director of Nursing | Completed progress note and investigation review related to verbal abuse incident. |
| STNA #218 | State Tested Nurse Aide | Witnessed verbal altercation between Resident #35 and LPN #242. |
| LPN #201 | Licensed Practical Nurse | Witnessed and intervened in verbal altercation between Resident #35 and LPN #242. |
| Administrator | Facility Administrator | Completed investigation with Regional Director of Clinical Services. |
| Regional Director of Clinical Services #245 | Regional Director of Clinical Services | Completed investigation with Administrator. |
| LPN #241 | Licensed Practical Nurse | Involved in medication administration errors for Resident #32. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Apr 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about food temperature, food safety, and sanitation in the facility's kitchen and meal service.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00151013.
Findings
The facility failed to ensure food was served at a safe and appetizing temperature, with food items being lukewarm or cold upon delivery. Additionally, the kitchen was found to be unsanitary with improperly dated and stored food items, uncovered coffee being transported in hallways, and dirty food tray lids. These deficiencies had the potential to affect 40 residents.
Deficiencies (2)
Food was served at an unappetizing temperature, with hot foods lukewarm and milk not cold enough.
Kitchen was not clean and sanitary; food items were not appropriately dated or stored; coffee was uncovered when transported down hallways.
Report Facts
Residents affected: 40
Facility census: 42
Residents receiving no food from kitchen: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | DM #307 involved in food temperature checks, interviews, and confirming sanitation issues | |
| State Tested Nursing Aide | STNA #306 observed transporting uncovered coffee down hallways | |
| License Practical Nurse | LPN #305 observed transporting uncovered coffee down hallways |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding bed bug infestation affecting Resident #10 and a fall incident involving Resident #38.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00149630 related to bed bug infestation and fall prevention failures.
Findings
The facility failed to ensure Resident #10's room was free of bed bugs despite multiple treatments and inspections, resulting in bed bug bites. Additionally, the facility failed to implement individualized fall prevention interventions for Resident #38, leading to a fall with injury.
Deficiencies (2)
Failed to ensure Resident #10's room was free of bed bugs despite multiple treatments and inspections.
Failed to ensure care and individualized fall prevention interventions for Resident #38, resulting in a fall.
Report Facts
Facility census: 37
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCCR #143 | Pest Control Company Representative | Provided information on bed bug inspections and treatments |
| MS #116 | Maintenance Supervisor | Interviewed regarding bed bug findings and mattress replacement |
| LPN #112 | Licensed Practical Nurse | Reported observations of bed bugs and resident skin condition |
| Administrator | Provided information on bed bug management and resident care | |
| RN/RDCS #144 | Registered Nurse/Regional Director of Clinical Services | Interviewed regarding Resident #38 fall and care plan |
| LPN/MDS #106 | Licensed Practical Nurse/Minimum Data Set | Confirmed Resident #38's fall risk and care plan interventions |
| DOR #142 | Director of Rehab | Provided therapy evaluations and recommendations for Resident #38 |
| STNA #138 | State Tested Nursing Assistant | Provided care information for Resident #38 |
| STNA #104 | State Tested Nursing Assistant | Witnessed Resident #38 fall and provided water prior to fall |
| LPN #145 | Licensed Practical Nurse | Involved in care of Resident #38 during fall incident |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 8
Date: Dec 28, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to unauthorized video recording and sharing of residents by a staff member, as well as other compliance issues including care planning, smoking assessments, catheter care, pharmacy recommendations, resident weight documentation, vaccination policies, and pest control.
Complaint Details
The complaint investigation was triggered by a facility self-reported incident involving a dietary staff member who video recorded two residents during an altercation and posted the video on social media. The investigation included interviews with residents, staff, and review of facility policies and camera footage. The incident was corrected prior to the survey with staff education and other corrective actions.
Findings
The facility failed to prevent unauthorized video recording of residents, failed to conduct timely care planning conferences, did not complete smoking assessments or care plans, failed to provide appropriate catheter care, did not follow up on pharmacy recommendations timely, inaccurately documented resident weights, failed to offer pneumococcal vaccinations as recommended, and had pest control issues in the kitchen area.
Deficiencies (8)
Failed to prevent unauthorized videos from being taken and shared on social media by a staff member involving residents.
Failed to ensure care planning conferences were conducted at least quarterly for residents.
Failed to complete assessments and care plans regarding resident smoking.
Failed to provide suprapubic catheter site care for a resident.
Failed to ensure pharmacy recommendations were followed up on in a timely manner.
Failed to ensure weights were documented accurately for a resident.
Failed to ensure pneumococcal vaccinations were offered and provided as recommended by CDC guidelines.
Failed to ensure food storage areas were free from pests, specifically drain flies in the kitchen.
Report Facts
Facility census: 39
Residents affected: 2
Dates of incident and correction: Incident occurred on 12/08/23, corrected by 12/12/23
Pharmacy recommendation follow-up delays: 3
Weights recorded: 4
Dates of pest control treatments: Routine pest control on 12/06/23, specific drain fly treatment on 12/26/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Services #845 | Regional Director of Clinical Services | Interviewed regarding the video recording incident and pharmacy recommendation follow-up |
| Dietary Assistant #846 | Dietary Assistant | Staff member who video recorded residents and posted video on social media |
| Human Resource Director #822 | Human Resource Director | Checked phone for video and interviewed staff |
| State Tested Nursing Assistant #801 | State Tested Nursing Assistant | Had video on phone and interviewed about incident |
| Licensed Practical Nurse #815 | Licensed Practical Nurse | Provided care conference note and interviewed about care planning |
| Admissions Coordinator/Social Worker Designee #842 | Admissions Coordinator/Social Worker Designee | Interviewed regarding care planning conferences |
| Registered Nurse #845 | Registered Nurse | Interviewed regarding care planning and pharmacy recommendations |
| Licensed Practical Nurse #901 | Licensed Practical Nurse | Assisted resident with smoking and interviewed about smoking care |
| Director of Nursing | Director of Nursing | Interviewed regarding smoking assessment and pharmacy recommendations |
| Activity Director #820 | Activity Director | Interviewed regarding smoking activities with residents |
| Registered Nurse #900 | Registered Nurse | Agency nurse interviewed about catheter care orders |
| Regional Registered Nurse #845 | Regional Registered Nurse | Interviewed regarding pharmacy recommendations |
| Administrator | Administrator | Interviewed regarding pharmacy recommendations and resident weight documentation |
| Registered Dietitian #847 | Registered Dietitian | Interviewed regarding resident weight documentation |
| Interim Infection Preventionist #845 | Interim Infection Preventionist | Interviewed regarding pneumococcal vaccination policies and resident eligibility |
| Dietary Director #834 | Dietary Director | Observed pest infestation in kitchen |
| Pest Control Services Representative #902 | Pest Control Services Representative | Interviewed regarding pest control treatments and sanitation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to initiate CPR and call 911 for Emergency Medical Services for Resident #37, who was found unresponsive and identified as full code status but did not receive CPR, resulting in the resident's death.
Complaint Details
The complaint investigation substantiated neglect when Resident #37 was found without vital signs and designated full code directives were not followed, and CPR was not initiated. The facility self-reported the incident and conducted a comprehensive investigation including record reviews and staff interviews.
Findings
The facility failed to initiate CPR or call 911 for Resident #37, who was found unresponsive without vital signs despite having a full code status. This resulted in immediate jeopardy and actual harm. The facility implemented corrective actions including staff education, audits, and system improvements to prevent recurrence.
Deficiencies (1)
Failure to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #37 who was found unresponsive and identified as full code status.
Report Facts
Residents affected: 1
Residents reviewed for death: 2
Facility census: 34
Tracking number: 239053
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #150 | Licensed Practical Nurse | Nurse on duty who failed to initiate CPR or call 911 for Resident #37 |
| RN #152 | Mobile Director of Nursing / Registered Nurse | Notified of Immediate Jeopardy and involved in corrective actions |
| RDCS | Regional Director of Clinical Services | Notified of Immediate Jeopardy and involved in corrective actions and staff education |
| Administrator | Facility Administrator involved in notification and corrective actions | |
| IDON #154 | Interim Director of Nursing | Initiated in-house education and involved in investigation |
| Physician #155 | Resident's Physician | Notified of resident's death and code status not honored |
| MD #156 | Medical Director | Involved in developing corrective action plan following incident |
| STNA #118 | State Tested Nursing Assistant | Provided care to Resident #37 and informed LPN #150 of full code status |
| STNA #121 | State Tested Nursing Assistant | Assisted with postmortem care for Resident #37 |
Inspection Report
Routine
Census: 36
Deficiencies: 23
Date: Jan 27, 2022
Visit Reason
The inspection was a routine survey of Crawford Manor Healthcare Center to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Complaint Details
Complaint OH00129450 substantiated related to call light system not functioning properly affecting six residents.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, inadequate notification of resident funds, failure to notify family of falls and room changes, physical abuse incident, incomplete employee reference checks, inadequate discharge and bed hold notifications, incomplete resident assessments, failure to provide showers and foot care, unsecured medications, improper infection control practices, failure to timely report COVID-19 cases, inadequate COVID-19 testing and PPE use, malfunctioning call lights, unsanitary environment, and inconsistent smoking policy implementation.
Deficiencies (23)
Failed to ensure Resident #32 ate in a dignified manner and failed to provide privacy cover for Resident #187's urinary catheter bag.
Failed to notify residents when account balances reached less than $200 below the SSI resource limit.
Failed to notify Resident #88's emergency contact following falls and room change.
Failed to ensure Resident #19 was free from physical restraints and failed to report physical abuse incident.
Failed to complete employee reference checks prior to hire as part of abuse screening.
Failed to implement abuse policy as STNA #646 failed to report physical restraint of Resident #19.
Failed to provide timely written notification of hospital discharges to residents and representatives.
Failed to notify residents of available bed hold days at time of hospital discharge.
Failed to comprehensively assess Resident #32's activity pursuit using the resident assessment instrument.
Failed to accurately complete comprehensive MDS assessments for five residents.
Failed to provide showers to Residents #33 and #88 who were dependent on staff for care.
Failed to provide appropriate foot care for Resident #33.
Failed to ensure unsecured medications were not left unattended on Resident #187's bedside table.
Failed to timely report and coordinate with Local Health Department regarding employee and resident COVID-19 positive cases.
Failed to ensure staff were tested per COVID-19 outbreak testing guidelines, had competency testing signed off, and wore gowns during resident testing.
Failed to ensure staff wore appropriate eye protection in the facility despite high county COVID-19 positivity rate.
Failed to ensure visitors and employees were screened for COVID-19 symptoms upon entry to the facility.
Failed to ensure annual tuberculosis symptom screening and skin test completion for multiple employees.
Failed to ensure residents and families were notified of positive COVID-19 cases of employees and residents.
Failed to ensure food was appealing, palatable, and served at an appetizing temperature.
Failed to maintain a clean and sanitary living environment and kitchen environment.
Failed to ensure residents' call lights were functioning properly.
Failed to consistently implement smoking policies and ensure congruence between policy, assessment, care plan, and smoking contracts.
Report Facts
Deficiencies cited: 23
Residents reviewed for activities: 3
Residents reviewed for abuse/SRI: 3
Residents reviewed for immunizations: 5
Residents reviewed for bed hold notification: 11
Residents reviewed for call light function: 36
Residents identified as smokers: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #633 | State Tested Nurse Aide | Named in dignity and meal service findings |
| Director of Nursing | Director of Nursing | Named in dignity, fall notification, and COVID-19 reporting findings |
| Business Office Manager #640 | Business Office Manager | Named in resident funds notification and COVID-19 testing findings |
| STNA #646 | State Tested Nurse Aide | Named in physical abuse and COVID-19 testing findings |
| Regional Director of Clinical Services #642 | Regional Director of Clinical Services | Named in abuse and COVID-19 reporting findings |
| Licensed Practical Nurse #622 | Licensed Practical Nurse | Named in dignity, medication administration, and COVID-19 testing findings |
| Administrator | Administrator | Named in fall notification, COVID-19 reporting, and screening findings |
| Housekeeper #631 | Housekeeper | Named in employee screening and smoking policy findings |
| Registered Nurse #617 | Registered Nurse | Named in employee screening findings |
| Resident #88's sister | Named in fall notification and COVID-19 screening findings | |
| Resident #31 | Named in call light and COVID-19 notification findings | |
| Resident #33 | Named in shower and foot care findings | |
| Resident #25 | Named in food quality and COVID-19 notification findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 22, 2019
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to ensure accurate advance directive orders and comprehensive care plans for certain residents.
Complaint Details
The visit was complaint-related, focusing on issues with advance directives and care planning. The deficiencies were substantiated as the facility failed to ensure accurate documentation and care plans for affected residents.
Findings
The facility failed to maintain accurate advance directive information for Resident #12 and did not develop comprehensive care plans addressing substance abuse for Resident #18 and oxygen level monitoring for Resident #5. These deficiencies affected a few residents and posed minimal harm or potential for actual harm.
Deficiencies (2)
Failed to ensure residents had accurate advance directive orders and information in the medical record for Resident #12.
Failed to develop and implement complete care plans related to substance abuse for Resident #18 and oxygen level monitoring for Resident #5.
Report Facts
Residents affected: 1
Residents affected: 2
Residents reviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #12's code status discrepancy | |
| acting Director of Nursing (DON) | Interviewed regarding care plan deficiencies for Residents #5 and #18 |
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