Lincoln Crawford Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 8, 2025

  Based on interview, record review, and facility document and policy review, the facility failed to protect 3 (Resident #55, Resident #58, and Resident #53) of 3 residents ' right to be free from physical/mental abuse by another resident. On 05/26/2025, before the evening meal in the dining room, dietary staff observed Resident #95 attempt to hit their roommate, Resident #55. Dietary staff separated the residents and instructed the residents to go upstairs. Later that evening, staff transferred Resident #55 to the emergency department (ED) due to bleeding from the resident ' s head. While at the ED, Resident #55 stated that Resident #95 hit them multiple times with a cane. […]

• Actual harm, isolatedF607Aug 8, 2025

  Based on interview, record review, and facility policy review, the facility failed to implement their policy for abuse prohibition for 1 (Resident #55) of 2 residents. Specifically, a dietary aide (DA) witnessed Resident #95 attempt to hit Resident #55 in the dining room on 05/26/2025. The staff member separated the residents and directed them to return to the unit where they resided; however, the incident was not reported to the Director of Nursing (DON), the nurse supervisor on duty, or Administrator as required per facility policy. Once Resident #55 returned to their room, the resident stated that Resident #95 struck them in their head with a cane. […]

• No harm, potential for more than minimal, widespreadF880Feb 17, 2022

  Based on record review, observations, staff interviews, review of the facility's policy, and review of online resources from the Centers for Disease Control (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in resident areas to prevent the potential spread of Coronavirus (COVID-19). This had the potential to affect all 94 residents residents residing in the facility. Findings include: 1. Review of the medical record for Resident #48 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Observation on 02/17/22 at 10:05 A.M. […]

• No harm, potential for more than minimal, patternF584Aug 8, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure 1 (300 hall) of 2 shower rooms were maintained in a clean condition. Findings included:An undated facility policy titled, Bathrooms revealed 1. Bathrooms, including showers, whirlpools, century baths, commodes, etc., will be cleaned daily in accordance with our established procedures.An observation on 08/04/2025 at 1:54 PM revealed the 300 hall shower room had pieces of cotton from a wound dressing on the shower floor in stall #1, the floor throughout the entire shower room appeared with a thick brown grime substance on the tiles, a large shower chair with a broken seat which exposed a jagged and sharp appearance along the inner ring, a shower bench/riser with dirty areas and white substance in spots… […]

• No harm, potential for more than minimal, patternF689Aug 8, 2025

  Based on observation, interview, record review, facility policy, and facility document review, the facility failed to consistently implement a program to ensure resident safety while smoking for 6 (Residents #6, #9, #4, #24, #31, and #49) of 29 residents who smoked. Specifically, the facility failed to ensure residents did not keep smoking materials in their possession and did not give smoking materials to other residents per the facility's smoking policy and smoking agreement. Findings included:A facility policy, Smoking Policy – Residents, revised 07/2017, revealed This facility shall establish and maintain safe resident smoking practices. The policy interpretation and implementation directed, 1. […]