Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincoln Crawford Care Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Abuse: Staff observed one resident attempt to hit a roommate in the dining room, but the resident later required ED transfer after being found bleeding and reported being assaulted with a cane, with hospital records showing a head laceration, sutures, a right ulna fracture, and acute blood loss anemia. In a separate courtyard incident, two cognitively intact residents argued during smoking time, exchanged physical aggression, and had to be separated by another resident; the facility documented both events as unsubstantiated or behavioral rather than abuse.
Failure to Report Resident-on-Resident Abuse: A dietary aide witnessed one resident attempt to hit another resident in the dining room, separated the residents, and sent them back to their units, but did not immediately report the incident to the DON, nurse supervisor, or Administrator as required by policy. The affected resident had hemiplegia, limited UE ROM, and required extensive assistance with ADLs, and later stated the other resident struck them in the head with a cane, resulting in bleeding and hospitalization. Staff interviews confirmed the event was not reported.
A facility failed to keep a shower room clean and safe, with observations of wound dressing material on the floor, thick grime, a broken shower chair, dirty benches, unlabeled personal care bottles, hair-clogged drains, and unsanitary toilet and sink conditions. Interviews with the Administrator, HD, and DON confirmed the room was not maintained according to policy, with unclear responsibilities for certain cleaning tasks.
Smoking Materials Not Secured or Supervised Consistently: A facility failed to consistently follow its smoking policy for multiple residents who smoked. Residents were observed keeping cigarettes or a lighter in their possession, and one resident passed cigarettes to another resident without staff present. Staff and the smoke guard stated residents were not supposed to keep smoking materials, but some did so anyway, despite smoking evaluations and agreements indicating the facility stored the materials and supervised smoking.
A resident with intact cognition and diagnoses including CHF, seizures, and chronic respiratory failure was receiving short-term rehab when Medicare Part A skilled coverage ended, but the facility did not provide the required SNF ABN while the resident remained in the facility. Records showed the ABN was not found, and interviews with the former SSD, BOM, DON, and Administrator confirmed the notice should have been issued along with the NOMNC.
Failure to Timely Report Resident-to-Resident Abuse: A resident with a BIMS of 15, wheelchair dependence, and anticoagulant use was struck on the head with a metal cane by another resident and sent to the hospital for a bleeding head injury. Staff interviews showed the incident was witnessed, but dietary staff did not report it at the time, and an agency LPN learned of the allegation only after the resident had been transferred. The Administrator stated he learned of the event the next morning and believed the report to the state agency had been timely.
Incomplete Abuse Investigations and Witness Interviews: The facility did not thoroughly investigate a resident-on-resident abuse allegation when a resident with intact cognition was found bleeding and later reported being assaulted by a roommate, despite hospital findings of a fractured arm, head laceration, and acute blood loss anemia. The investigation lacked interviews with multiple staff and a resident witness, and the roommate’s fall explanation was accepted as unsubstantiated. The facility also failed to fully investigate a separate altercation between two residents, including not interviewing a resident witness and not documenting activity checks for one resident.
Failure to keep a resident's fingernails trimmed and clean. A resident with dementia, DM2, ASHD, and CKD was dependent on staff for ADLs and had a care plan addressing nail care, but observations showed long, dirty, jagged fingernails on multiple occasions. Staff gave inconsistent accounts of who was responsible for nail care, and the resident stated they were waiting on staff to trim the nails.
A cognitively impaired resident was treated in an undignified manner when a dietician offered him a banana and made a comment comparing him to a monkey. The incident was reported by an STNA who observed the resident's confused and disappointed reaction. The dietician expressed remorse, stating the phrase was commonly used with her grandchildren. The facility's investigation into the incident was questioned by the reporting STNA, who claimed her initial statement was lost.
A resident with chronic osteomyelitis and diabetes did not receive the ordered wound care treatment for their right heel. An LPN failed to perform the treatment due to time constraints and falsely documented it as completed. The dressing observed was not as ordered, and the facility's wound care policy was not followed.
A facility failed to implement enhanced barrier precautions and proper hand hygiene during wound care for a resident with chronic osteomyelitis and diabetes. An LPN used a different dressing than ordered and did not perform hand hygiene after removing gloves, only wearing gloves as PPE. The facility's policies on wound care, enhanced barrier precautions, and hand hygiene were not followed, as confirmed by the DON.
A facility failed to provide appropriate incontinence and catheter care for a resident with multiple diagnoses, including neurogenic bladder. An STNA did not follow proper procedures, such as changing gloves and cleaning the catheter area correctly, as per facility policies. This deficiency was identified during a complaint investigation.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents in two separate incidents. In one incident, Resident #55, who had a history of hemiplegia/hemiparesis after a cerebral infarction, cerebrovascular disease, intact cognition on MDS, limited upper-extremity range of motion, and was receiving clopidogrel and apixaban, was involved in an altercation with Resident #95, who also had intact cognition on MDS and a history of peripheral vascular disease, depressive disorder, and mild cognitive impairment. Dietary staff observed Resident #95 attempt to hit Resident #55 in the dining room and separated the residents, but later that evening Resident #55 was found bleeding from the head and sent to the ED. At the hospital, Resident #55 reported that Resident #95 assaulted them with a cane and struck them multiple times. Hospital records documented a forehead laceration requiring six sutures, a right ulna fracture, acute blood loss anemia, and trauma admission. After the incident, Resident #55 stated they had been hit on the head and wrist with a cane and denied falling. Staff interviews reflected that multiple employees heard or saw parts of the confrontation, including Resident #62, dietary aides, CNA #28, and LPN #16, but the facility initially documented the event as a fall and did not substantiate abuse. The DON stated the facility did not credit Resident #55’s account and the Administrator stated he viewed the situation as behavioral rather than abusive. In a second incident, Resident #53 and Resident #58, both with intact cognition on MDS, became involved in an altercation in the courtyard during smoking time. Resident #53 reported hearing Resident #58 talking about them, and Resident #58 reportedly used an expletive toward Resident #53’s family member and pushed Resident #53 away. Resident #53 then hit Resident #58 in the face and placed hands around Resident #58’s neck, and Resident #31 separated them. The facility’s incident summary stated both residents claimed the other was the aggressor, police were called at both residents’ request, and the event was unsubstantiated with abuse not suspected.
Failure to Report Resident-on-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prohibition policy when a dietary aide witnessed Resident #95 attempt to hit Resident #55 in the dining room and did not report the incident to the DON, nurse supervisor, or Administrator as required. The facility policy stated that any suspected or observed abuse must be immediately reported to facility management, including the DON, nurse supervisor on duty, or Administrator, and that the Administrator or DON must be immediately notified regardless of the time lapse since the incident occurred. Resident #55 had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left side, cerebrovascular disease, and limited upper extremity range of motion. The resident’s care plan identified the resident as needing assistance with eating, hygiene, toileting, transfers, bathing, and mobility. Resident #95 had diagnoses including peripheral vascular disease, depressive disorder, and mild cognitive impairment, and the resident’s MDS showed intact cognition. According to interviews, Resident #55 and Resident #62 were in the dining room when Resident #95 approached, bumped Resident #55’s wheelchair, and attempted to hit the resident. A dietary aide separated the residents and told them to go upstairs, then returned to kitchen duties without reporting the incident. Resident #55 later stated that after returning to the room, Resident #95 struck them in the head with a cane, causing bleeding. Resident #62 and both dietary aides described the confrontation and confirmed that no report was made. The DON stated staff were expected to notify management immediately, and the Administrator stated that attempted hitting would be abusive and should have been reported right away.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain the 300 hall shower room in a clean and safe condition, as required by its own policy and regulatory standards. Observations revealed the presence of cotton from a wound dressing on the shower floor, thick brown grime on the tiles, a large shower chair with a broken and jagged seat, a shower bench with dirty areas and a white substance on the seat, rusty metal legs, and multiple open and unlabeled bottles of personal care products. The shower nozzle was hanging down, and thick black hair was covering all the drains in the three shower stalls. Additionally, a toilet in the common area lacked a privacy curtain, contained feces and brownish rings, and the handwashing sink had rust-colored rings with a large puddle of water on the floor between the toilet and sink. Interviews with the Administrator, Housekeeping Director (HD), and Director of Nursing (DON) confirmed that the shower room's condition was not in compliance with facility expectations. The Administrator acknowledged the issues, including the presence of dressing material, unclean toilet, broken chair, standing water, and dirty sink. The HD stated that the assigned housekeeper was responsible for daily cleaning but was unsure who was responsible for removing hair from the drains, and noted that the water puddle was due to a leak. The DON indicated that aides were expected to tidy up after each resident's use, with housekeeping responsible for mopping and sanitizing the area at least once or twice daily. The deficiency was identified during an investigation under two complaint numbers.
Smoking Materials Not Consistently Controlled
Penalty
Summary
The facility failed to consistently implement its smoking safety program for six residents who smoked, because residents were observed keeping smoking materials in their possession and, in one instance, passing cigarettes to another resident. The facility policy stated residents were not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, lighters, matches, or other smoking articles in their possession and were not permitted to give smoking articles to other residents. The policy also stated the facility maintained the right to confiscate smoking articles found in violation of the smoking policy. Resident #6 had diagnoses including dementia, COPD, tobacco use, bipolar disorder, and anxiety. Although the resident’s smoking safety evaluation indicated the resident could smoke unsupervised and returned smoking materials for storage, a pack of cigarettes was observed on the resident’s bed. The resident stated staff kept the lighter and that the resident was not supposed to keep the cigarettes, but had kept them because the resident was not feeling well and planned to turn them in later. Resident #9 had diagnoses including flaccid hemiplegia, psychotic disorder, nicotine dependence, and PTSD. The resident’s smoking evaluation indicated supervision was required and that smoking materials were stored by the facility. However, the resident was observed asking a CNA to get cigarettes from the resident’s room, then grabbing the cigarettes out of the CNA’s hand and taking them outside to the smoking area. The resident stated the cigarettes belonged to another resident. Resident #24, who had diagnoses including skin infection, MRSA infection, morbid obesity, and opioid use, was observed with a cigarette lighter hanging from the front of the resident’s shirt even though the smoking agreement stated cigarettes and lighting materials were to be kept locked at the nurses station and not kept in the resident’s possession. Resident #4 and Resident #49 were observed in the hallway near the elevator when Resident #4 passed two cigarettes to Resident #49 in a secretive manner with no staff present or witnessing the exchange. Resident #31, who had quadriplegia, chronic pain syndrome, depression, anxiety, and muscle wasting, was observed with two cigarettes in the resident’s lap in the hallway by the receptionist desk. The smoke guard and other staff stated residents were not supposed to keep cigarettes or lighters, but some residents did so and staff monitored them or reported noncompliance.
Failure to Provide SNF ABN When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) to Resident #14 when Medicare Part A skilled services ended and the resident remained in the facility with benefit days remaining. The facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, stated that the SNF ABN is issued when the facility proposes to stop furnishing extended care items or services because it expects Medicare will not continue to pay and the beneficiary wants to continue receiving care. Resident #14 was admitted on 08/12/2024 with diagnoses including seizures, congestive heart failure, and chronic respiratory failure with hypoxia. The resident’s MDS assessment dated 02/04/2025 showed a BIMS score of 15, indicating intact cognition, and the care plan identified the resident as receiving short-term rehabilitation with planned discharge to the community after skilled nursing care and therapy. The Beneficiary Notice Scenarios for Surveyors form showed the resident’s Medicare Part A skilled services episode began on 02/01/2025 and the last covered day was 03/14/2025. The facility record indicated the SNF ABN was not provided, and an unsigned handwritten note stated it was unable to be found and may not have been done. During interviews, the former SSD, BOM, DON, and Administrator each stated that residents remaining in the facility after Medicare Part A coverage ends should receive both a NOMNC and an SNF ABN, and they identified the former SSD as responsible for providing the notices to Resident #14. The former SSD stated she was not sure why the ABN was not provided and was not sure where it was.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse to the Administrator and to the state survey agency within two hours for one resident who was struck on the head with a metal cane by another resident and sustained bleeding from a head injury that required transfer to the hospital for evaluation. The facility’s Abuse and Neglect Protocol stated that the Administrator or DON must be immediately notified of suspected abuse or incidents of abuse and that suspected abuse resulting in serious bodily injury must be reported immediately, but not later than 2 hours after forming the suspicion. The policy also stated that alleged violations involving abuse are to be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse, with or without serious bodily injury. The injured resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, other cerebrovascular disease, PTSD, adjustment disorder, and depression. The resident’s annual MDS showed a BIMS score of 15, no behaviors, wheelchair use for mobility, supervision or touch assistance for transfers, and anticoagulant use. The other resident involved also had a BIMS score of 15 on a quarterly MDS and used a wheelchair, with some ability to ambulate short distances and requiring varying levels of assistance for wheeling. The State Reportable Incident Report stated that the injured resident was found bleeding and made an allegation of physical abuse against the other resident. The resident was sent to the hospital and reported there had been an assault by the roommate, while the roommate reported that the resident had fallen from the wheelchair. Interviews with the injured resident, another resident who witnessed part of the interaction, and dietary staff described an altercation in which the other resident bumped the wheelchair, swung at the resident, and later struck the resident in the room with a metal cane, causing the head injury. A dietary aide who witnessed the incident stated she heard a resident yell for the other resident to stop, saw the other resident swing at the injured resident, and did not report the event at the time because she returned to kitchen duties. Another dietary aide stated she heard noise and yelling for help and also did not report the event because she was busy completing nightly duties. An agency LPN stated she learned of the allegation only after the resident had been sent out and that the allegation was not reported until shift report the next morning. The Administrator stated he learned of the event the following morning and believed the event had been reported timely to the state agency.
Incomplete Abuse Investigations and Witness Interviews
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was sent to the emergency department after being found bleeding from the head. Resident #55 had a history of hemiplegia/hemiparesis following a cerebral infarction, cerebrovascular disease, and intact cognition on the most recent MDS. The resident was diagnosed at the hospital with a fractured right arm, a head laceration with an arterial bleed, and acute blood loss anemia. Before leaving the facility, the resident did not explain how the injury occurred, while the roommate, Resident #95, reported that the resident had fallen. After arrival at the hospital, Resident #55 told staff that Resident #95 had hit them multiple times with a cane, and later stated the roommate had struck them with a metal walker and then with a cane. The facility investigation did not document interviews with all staff who had knowledge of the incident and did not document an interview with a resident who witnessed an altercation between the two residents. The investigation also did not include documented interviews with Resident #62, DA #21, DA #22, CNA #19, or LPN #16, even though these individuals later described what they saw or heard related to the event. Facility staff reviewed the resident’s room and items in the room and concluded the resident’s account was inconsistent, determining that abuse was not suspected and was unsubstantiated, despite the resident repeatedly reporting assault and despite staff observations that the injuries did not appear consistent with the fall explanation. The facility also failed to thoroughly investigate a separate resident-to-resident altercation involving Resident #53 and Resident #58. Both residents had intact cognition on MDS assessments, and the incident was reported as a physical abuse event after an altercation in the courtyard. The facility interviewed the two residents, but the investigation did not include an interview with Resident #31, who stated they witnessed the residents arguing and physically fighting and intervened to break it up. The facility also did not provide documented activity checks for Resident #53, and the investigation documents showed one-to-one observation was provided for Resident #58 but not for the other resident involved. The Administrator stated the facility should have interviewed all witnesses and expected staff to interview anyone present at the time of the incident.
Failure to Keep a Resident's Fingernails Trimmed and Clean
Penalty
Summary
The facility failed to keep the fingernails of Resident #33 trimmed and clean despite the resident being dependent on staff for activities of daily living. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, atherosclerotic heart disease, and chronic kidney disease. The quarterly MDS indicated the resident was cognitively intact, had not rejected care during the assessment period, and required setup assistance with personal hygiene and partial to moderate assistance with bathing. The care plan identified the resident as at risk for complications related to an ADL performance deficit and included checking nail length and trimming and cleaning nails on bath day and as needed. Observations showed Resident #33 had long fingernails, with several appearing 3/4 to 1 inch long, and later the nails were still dirty, long, and jagged. The resident stated they were waiting on staff to trim the nails and that staff trimmed them whenever they wanted to. Staff interviews reflected inconsistent understanding of who was responsible for nail care, with some stating CNAs trimmed nails on shower days or as needed, while others stated nurses trimmed nails for residents who were diabetic. The resident's shower sheets showed showers were refused on four of five days over the previous two weeks, and the record showed the resident received a shower and nail trimming on one date during that period.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by an incident involving a dietician and a resident with cognitive impairment. The resident, who had vascular dementia, type two diabetes, and lumbago with sciatica, was approached by the dietician who offered him a banana and made a comment comparing him to a monkey. This comment was reported by a State Tested Nursing Assistant (STNA) who witnessed the interaction and noted the resident's confused and disappointed reaction. The dietician later expressed remorse, stating that the phrase was a common refrain used with her grandchildren and that no harm was intended. The incident was reported to the Assistant Director of Nursing (ADON) and the Administrator, who spoke with the dietician about the situation. However, the STNA who reported the incident claimed that the facility did not properly investigate the concern and that her initial written statement was lost. The facility's document on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, which was not upheld in this instance. This deficiency was investigated under a specific complaint number, indicating non-compliance with resident rights.
Failure to Complete Ordered Wound Treatment
Penalty
Summary
The facility failed to ensure that wound treatment was completed as ordered for a resident, leading to a deficiency. Resident #81, who was cognitively intact and had diagnoses including chronic osteomyelitis and diabetes mellitus, was affected by this failure. The physician's order specified a detailed wound care regimen for the resident's right heel, which included cleansing with normal saline, applying betadine, calcium alginate with silver, and covering with specific dressings. However, during an observation, it was found that the dressing applied was not as ordered, and the treatment had not been performed for a couple of days. An interview with the resident confirmed that the dressing had not been changed in a couple of days. Further investigation revealed that an LPN had not completed the treatment as ordered on a specific day due to time constraints and had falsely signed off the treatment as completed. The Director of Nursing confirmed that it was unacceptable to not complete treatments as ordered by the physician. The facility's wound care policy outlined the proper procedure for wound care, which was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions and proper hand hygiene during wound care for a resident. The resident, who was cognitively intact, had diagnoses including chronic osteomyelitis and diabetes mellitus. A physician's order specified a particular wound care treatment for the resident's right heel, which included cleansing with normal saline, applying betadine, and using calcium alginate with silver. However, during an observation, an LPN was seen using a different dressing than ordered and did not perform hand hygiene after removing gloves, which is against the facility's policy. The LPN only wore gloves as personal protective equipment, failing to use the required gown and gloves for enhanced barrier precautions. The facility's policies on wound care and enhanced barrier precautions were not followed, as confirmed by the Director of Nursing. The facility's hand hygiene policy also mandates handwashing before and after certain tasks, which was not adhered to during the wound care procedure.
Inadequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who was incontinent of bowel and had an indwelling urinary catheter. The resident, who had diagnoses including chronic obstructive pulmonary disease, coronary artery disease, peripheral vascular disease, contractures to his bilateral lower extremities, and neurogenic bladder, required substantial assistance from staff for toileting. During an observation of incontinence care, a State tested Nursing Assistant (STNA) did not follow proper procedures for catheter care and incontinence care. The STNA did not change gloves during the process, did not clean around the penis or the tubing coming out of the penis, and did not follow the facility's policy for perineal and catheter care. The STNA confirmed these lapses in procedure during an interview, stating that this was not her normal practice. The facility's policies for perineal care and catheter care were reviewed and found to include specific steps for cleaning the perineal area and catheter, which were not followed by the STNA. The policies emphasized the importance of cleanliness to prevent infections and skin irritation. The failure to adhere to these policies resulted in inadequate care for the resident, who was at risk for developing complications due to bowel incontinence and the presence of an indwelling urinary catheter. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for incontinence and catheter care, with the facility having a total of 48 residents who were incontinent of bowel and five residents with indwelling catheters.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 916 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carecore At Margaret Hall | 0.8 mi | ★★★★★ | 12 | 0 |
| Beechwood Home For Incurables | 1.1 mi | ★★★★★ | 1 | 0 |
| Garden Park Health Care Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Astoria Place Of Cincinnati | 1.5 mi | ★★★★★ | 42 | 0 |
| Norwood Towers Post-acute | 2.1 mi | ★★★★★ | 30 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lincoln Crawford Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.