Crawford Manor Healthcare Center

In the surveyor’s words

From the most serious findings on record at Crawford Manor Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 20, 2024

  THE 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. […]

• Immediate jeopardy, isolatedF678Sep 25, 2023

  THE 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. […]

• Actual harm, isolatedF689Apr 23, 2026

  THE 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. […]

• No harm, potential for more than minimal, widespreadF804Apr 2, 2024

  Based 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. Findings include: Observation on 03/28/24 at 11:39 A.M. of Dietary Cook #308 taking the temperatures of the lunch meal items prior to food service revealed the chicken tenders were 173 degrees Fahrenheit (F), the [NAME] fries were 165 degrees F, the carrots were 162.1 degrees F, the white slice of bread was room temperature, and the chocolate cake was room temperature. Tray service for hall trays began on 03/28/24 at 11:50 A.M. […]

• No harm, potential for more than minimal, widespreadF812Apr 2, 2024

  Based 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. Findings include: 1. Observation and interview during initial kitchen tour on 03/28/24 from 11:15 A.M. to 11:39 A.M. with Dietary Manager (DM) # 307 revealed the following concerns: On the bread rack was a one gallon unlabeled and undated storage bag full of Danishes. […]