Crawford Manor Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate assistance with ADLs and bed mobility to prevent an avoidable fall with injury. A resident with hemiplegia, dementia, muscle weakness, impaired mobility, and a history of falls had a comprehensive care plan and therapy recommendations in place requiring two-person assistance for bed mobility, transfers, toileting, and bathing, as well as use of a mechanical lift for transfers. The most recent MDS documented that the resident was severely cognitively impaired and required extensive assistance with ADLs and mobility. On the night of the incident, a CNA who had just completed facility orientation the prior day provided care to the resident alone. The CNA reported that she was getting the resident ready for bed, undressed him to clean him, and then left the room to obtain clean bed sheets. Upon returning, she moved the resident’s bed closer to the wall, locked the bed wheels, and began cleaning the resident. While rolling the resident in bed to clean him, the resident rolled over the side of the bed and fell to the floor between the bed and the wall. The CNA then checked on the resident and went to get a nurse. When the nurse arrived, the resident was found on the floor between the bed and the wall. A head-to-toe assessment identified an abrasion on the right shin and later a laceration on the left foot. The nurse and CNA used a Hoyer lift to return the resident to bed, and the nurse informed the CNA that any resident requiring a Hoyer lift must always be assisted by two staff members for all care. Subsequent documentation showed the resident experienced increased left foot pain following the fall, and the laceration required hospital evaluation and treatment, including six sutures. The facility determined that the CNA did not follow the resident’s care plan and therapy recommendations requiring two-person assistance for all ADLs and bed mobility, and that this failure resulted in the resident’s fall and injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from resident-to-resident sexual abuse. One resident with a known history of inappropriate behaviors and a recent conviction for gross sexual imposition engaged in non-consensual sexual contact with another resident. The facility’s own documentation indicated that this resident required behavioral monitoring, supervision, and intervention to ensure the safety of others, yet he was in a position to have direct, unsupervised access to a cognitively impaired resident in a hallway. The resident identified as the aggressor had multiple medical and psychosocial conditions, including type II diabetes mellitus, hypertension, history of cerebral infarction, altered mental status, muscle weakness, history of falls, and an adjustment disorder with mixed anxiety and depressed mood. Hospital paperwork also documented that he had been incarcerated multiple times and was recently convicted of gross sexual imposition. Despite this history and the documented need for supervision due to inappropriate behaviors, he was able to wheel himself past another resident seated in a wheelchair in the hallway and initiate inappropriate sexual contact. The resident identified as the victim had severe intellectual disabilities, muscle weakness, and intractable localization-related epilepsy with complex partial seizures, and was documented as rarely or never understood with severely impaired cognitive skills for daily decision making. Nursing notes and a self-reported incident described that the aggressor pulled at the elastic waistband of the victim’s pants and brief and placed his hand inside the brief, touching the victim’s private area. A CNA witness corroborated that upon exiting the elevator, he observed the aggressor pulling the victim’s pants and brief out and placing his hand inside to touch the victim’s private area. Staff then intervened and separated the residents. The facility’s abuse prevention policy defined sexual abuse as non-consensual sexual contact of any type and required assessment and supervision of residents with behaviors that may lead to abuse, but the incident occurred despite these policy requirements, resulting in confirmed resident-to-resident sexual abuse. The facility’s investigation, as confirmed by the Administrator and DON, verified that the aggressor was observed pulling at the victim’s pants and brief and inappropriately touching her private area. Nursing documentation indicated that when confronted, the aggressor acknowledged awareness that he was touching someone’s private area and proceeded to make sexually inappropriate and explicit comments to the nurse. The victim, due to baseline cognitive impairment, was unable to provide a reliable account of the incident, but assessments documented no physical signs of trauma and no voiced complaints of pain or discomfort at that time. The combination of the aggressor’s known history and behavioral risks, the victim’s severe cognitive impairment, and the occurrence of non-consensual sexual contact in a common area formed the basis of the cited deficiency for failure to ensure residents were free from abuse. The facility’s abuse prevention policy, dated 08/25/25, required staff to immediately report, investigate, and implement interventions to protect residents from abuse, and further required assessment and supervision of residents with behaviors that may lead to abuse. Despite these written requirements, the incident occurred when the resident with a documented history of inappropriate behaviors and a recent conviction for a sexual offense was able to access and inappropriately touch a cognitively impaired resident in the hallway. The facility’s confirmation of the allegation as resident-to-resident sexual abuse, supported by staff and witness statements and nursing documentation, demonstrates that the facility did not effectively prevent the abusive contact from occurring. This deficiency was cited as past non-compliance that had been corrected prior to the survey, but the underlying incident and investigation findings clearly established that the facility failed to ensure residents were free from resident-to-resident sexual abuse as required by its own policy and regulatory standards.

Penalty

Inspection fine: $10,845

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and intervention to prevent a resident with a history of wandering from leaving the facility without staff knowledge. The incident occurred when the resident, who had been admitted to the facility with a history of heart failure, hypertension, memory loss, and a steady gait, left the facility on foot with his rollator walker. The resident was missing for approximately one hour and 45 minutes before being found by his nephew in the garage of his previous home, approximately five miles from the facility. The deficiency was identified when a staff member heard the door alarm sound but turned it off without investigation, assuming it was activated by a food delivery person. The resident was not identified as an elopement risk in the initial assessment, despite having a history of wandering noted in the hospital paperwork. The resident's absence was discovered when a nurse went to obtain vital signs and found the resident missing from his room. The facility's failure to investigate the door alarm and properly assess the resident's risk for elopement led to the resident's unsupervised departure. The incident was further compounded by the lack of a designated power of attorney or guardian for the resident, and the absence of a completed Minimum Data Set assessment. The facility's elopement policy was not effectively implemented, resulting in the resident's exposure to severe winter weather conditions and potential harm.

Removal Plan

• A facility wide search of both the internal and external facility property and surrounding areas was initiated.
• LPN #237 notified the Director of Nursing (DON) that Resident #33 was missing.
• The LPN then notified the police. The DON notified the Administrator and Resident #33's family.
• The facility staff completed a head count and identified no other residents were missing. All other residents were accounted for in the facility.
• Alarms on all doors were validated by the Regional Director of Clinical Services (RDCS) #245 for proper function and sound including annunciation to the second-floor nursing unit.
• An Elopement Drill was conducted by the Administrator, the DON, and Assistant Director of Nursing (ADON) #240 and then conducted each shift for 72 hours by one of the following Leadership team members: the Administrator, the DON, LPN/ Minimum Data Set (MDS) #218, LPN/ Charge Nurse (CN) #237, or ADON #240.
• An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review plan / progress with the Medical Director.
• The Administrator conducted facility window checks to ensure all were secured with stop brackets to limit less than six-inch opening.
• RDCS in conjunction with the Administrator validated the function of the outside exits, front door, back door (employee entrance) extending inspection beyond what the security camera observations that were completed, to include the third floor East stairwell door, third floor [NAME] stairwell door, second floor East stairwell door, second floor [NAME] stairwell door, first floor [NAME] exit door, therapy exit Door (end of hallway across from employee entrance).
• ADON #240 completed updated elopement observations for current residents, reviewed plan of care and updated as indicated for risk and interventions.
• The Administrator and ADON #240 completed the audit and update of the Elopement binders to reflect residents that are currently identified as risk for elopement (#1, #12, #20, #24, #27, #32, #34).
• The DON completed review of current residents Leave of Absence (LOA) orders, updated as indicated, reviewed plan of care and updated as indicated.
• DON and ADON #240 completed updated smoking observations for the current residents who smoked (#2, #7, #8, #10, #17, #18, #27, #32, #35, and #36), reviewed each resident's plan of care and updated as indicated.
• The Administrator and DON completed staff education related to resident safety including elopement risk and interventions, and importance of alarm response and investigation.
• The Administrator completed the education of the Admissions Director related to the review of hospital paperwork prior to admission to identify special needs/safety concerns and communicate special needs with facility team.
• The Administrator and DON completed education of staff on what to do if a resident was stating they want to go home or leave the facility, or if they observe exit seeking behaviors.
• The Administrator and DON completed educating staff on how to identify resident smoking status if they had a resident state they were going outside to smoke.
• Residents with a Brief Interview for Mental Status (BlMS) score 12 or above were educated that if they hear another resident making statements that they wanted to get out of the facility/[NAME] Manor they report to a staff member so that they could implement interventions for resident safety and determine if discharge planning was appropriate.
• The Administrator contacted the contracted provider (Alta Protection Services) requesting service for the rear door staff entrance and front door due to the identified sensitivity related to the winds setting off the door alarms when no human activity taking place at the doors.
• Second floor staffing distribution, beginning night shift, would assign one team member to remain at the nursing station desk to be available to respond to door alarms.
• The Administrator purchased audible monitors to be placed in the stairwell by first floor east and first-floor west outside exits, as it was determined that when the hallway door was closed the alarm sounding by the outside exit in the stairwell cannot be heard midway down the hall where the door monitor was located.
• The Administrator, DON, or Designee would conduct an elopement drill on every shift for 72 hours beginning day shift, then weekly for four weeks, then monthly for two months.
• Administrator, DON, or Designee would conduct elopement/ door alarm drills five times per week on various shifts for four weeks then monthly for two months for validation of appropriate staff response to triggered alarms and to ensure that staff are fluent with the alarm response process.
• Admissions/ re-Admissions referral information would be reviewed by the Director of Nursing/Designee to ensure risks were identified and interventions implemented.
• Administrator or Designee would audit scheduled smoking breaks two times per day, five times per week for four weeks then monthly for two months to ensure that residents assessed to smoke with supervision are being supervised during smoke breaks.
• Administrator or Designee would interview three residents two times per week for four weeks then monthly for two months to determine if they have heard another resident making statements that they want to get out of the facility/[NAME] Manor and if it was reported to facility staff.
• Administrator or Designee would interview three staff members two times per week for four weeks then monthly for two months related to what they would do in response to door alarms, residents saying they are going smoking and if a resident makes a statement they want to get out of the facility/[NAME] Manor.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was free from verbal abuse, affecting one resident out of three reviewed for abuse. The incident involved a resident who was cognitively intact and had a history of fractures, bipolar disorder, and anxiety. The resident reported being verbally abused by an LPN, who allegedly yelled and cursed at her after a disagreement over medication administration. The resident claimed she was startled but not physically hurt by the encounter. The investigation into the incident revealed conflicting accounts. The resident alleged that the LPN did not provide her with the requested pain medication and instead gave her a melatonin pill. The resident reported that when she confronted the LPN, she was met with verbal abuse. The LPN denied the allegations, stating she had administered the medication and had always been kind to the resident. However, witness accounts from other staff members corroborated the resident's claims of verbal abuse, with one STNA and another LPN confirming the LPN's use of degrading language towards the resident. The facility's policy on abuse clearly states that verbal abuse, defined as the use of disparaging and derogatory language, is not tolerated. Despite this policy, the investigation found that the LPN engaged in verbal abuse, as confirmed by witness testimonies. The incident was initially unsubstantiated, but further interviews revealed that the LPN did indeed use inappropriate language, leading to the deficiency being noted under the complaint number OH00158631.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident, identified as Resident #35, who was cognitively intact and had a history of making false accusations. The incident allegedly occurred over a weekend when the resident reported being yelled at and cursed by an LPN. The facility's investigation was deemed insufficient as it did not include interviews with all staff present during the alleged incident, only interviewing the accused LPN and other staff not present at the time. The investigation file lacked interviews from key staff members who were on duty during the shifts when the incident was reported to have occurred. Interviews with other staff members, conducted later, revealed that there were indeed altercations between the resident and the LPN, with both parties yelling and cursing at each other. One STNA and another LPN confirmed witnessing the LPN using degrading language towards the resident, which was not captured in the initial investigation. The facility's policy on abuse requires interviewing all witnesses and those in close contact with the resident and accused during the incident. However, this protocol was not followed, as confirmed by the facility's Administrator and Regional Director of Clinical Services. The failure to conduct a comprehensive investigation and interview all relevant staff members led to the deficiency being cited during the complaint investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45% due to two medication errors out of 31 opportunities. This deficiency affected one resident who was reviewed for medication administration. The resident, who was cognitively intact and required assistance with personal hygiene and dressing, had diagnoses including chronic idiopathic constipation and centrilobular emphysema. The resident's care plan included the use of nebulizers for emphysema. During a medication administration observation, it was noted that the resident's prescribed sennosides-docusate sodium tablet was unavailable for the morning dose, and the arformoterol solution for nebulization was not stored properly and was also unavailable. Later, the LPN administered geri-kot, which did not include the required docusate sodium component, resulting in the resident not receiving the correct medication as per the physician's orders. The facility's policy on medication administration, which requires verification of the correct medication, dose, and time, was not followed, leading to this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store medication according to the manufacturer's recommendations, affecting one resident who was being treated for centrilobular emphysema. The resident was prescribed arformoterol solution for nebulization, which was to be administered every 12 hours. During an observation of medication administration, it was found that the arformoterol solution was stored improperly in the bottom drawer of the medication cart, rather than being refrigerated as required. The medication was found in an opened foil pouch with two remaining doses, and the expiration date was not visible. The facility's policy on the storage and expiration dating of medications and biologicals requires that medications be stored according to manufacturer guidelines, including appropriate temperature ranges. The policy also mandates that expired or improperly stored medications be separated from other medications until they are destroyed or returned to the pharmacy. The Licensed Practical Nurse confirmed that the arformoterol solution was not stored correctly, resulting in its unavailability for the morning administration. This deficiency was identified during a complaint investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure food was served at an appetizing temperature, affecting 40 residents who received meals. Observations revealed that the temperatures of lunch items were taken before service, with chicken tenders at 173°F, fries at 165°F, and carrots at 162.1°F. However, delays occurred as the kitchen staff waited for dome lids to be brought up and washed, resulting in food being plated and left uncovered. By the time the food was served, the temperatures had dropped significantly, with chicken tenders at 116.8°F, fries at 115°F, and carrots at 117°F. Milk was also found to be warm at 51.4°F. Interviews with residents confirmed that the food was cold or tepid when delivered to their rooms. The Dietary Manager confirmed that the delay in obtaining and washing the dome lids negatively affected the food temperatures. The facility's policy on meal service, which requires hot foods to be served hot and cold foods cold, was not adhered to. This deficiency was investigated under Complaint Number OH00151013, highlighting the facility's non-compliance with its own food service policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the kitchen was clean and sanitary, and food items were appropriately dated. During an initial kitchen tour, several issues were observed, including an unlabeled and undated storage bag of Danishes, an undated metal pan of raw pork loin stored above milk cartons, and an unlabeled container of grape jelly with an old date sticker. Additionally, a container of fruit salad with a fermented smell was found, and the dry storage area had a buildup of dirt and debris, along with an open bag of basmati rice. The lids covering the food on the tray line were also found to be dirty. The Dietary Manager confirmed these observations and acknowledged that the items were not stored or labeled according to the facility's policies. The facility also failed to ensure that coffee was covered when being transported down the hallways. Observations revealed that a State Tested Nursing Aide and a Licensed Practical Nurse walked down the hallway with uncovered cups of coffee on residents' trays. The Dietary Manager confirmed that there were no lids on the beverage cart and that coffee should have been covered when transported. Interviews with the staff confirmed that the kitchen did not normally send lids for the coffee cups. These deficiencies were investigated under Complaint Number OH00151013.