Crandall Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record reviews, observations, staff interviews and facility policy review, the facility failed to maintain dignity while dining. This affected three residents (#85, #88, #93) of three reviewed for dignity. The facility census was 112.Findings include:1. Review of the medical record for Resident #85 revealed he was admitted on [DATE] with diagnoses that included dysphagia, major depressive disorder, and presence of cardiac pacemaker. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was dependent on staff for activities of daily living (ADL) and had a Brief Interview for Metal Status (BIMS) score of seven indicating severe cognitive impairment.2. Review of the medical record for Resident #88 revealed he was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare, fracture of the right femur, and nocturia. Review of the MDS assessment dated [DATE] revealed Resident #88 was dependent on staff for ADL and had a BIMS score of four,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide ordered mobility interventions for Resident #10. This affected one resident (#10) of one resident reviewed for range of motion. The facility census was 112.Findings include:Record review of Resident #10 revealed he was admitted [DATE] and had diagnoses including cerebral infarction, Parkinson's disease, neurocognitive disorder with [NAME] bodies, and dementia. Review of his orders revealed one dated 06/20/24 for the resident to wear a foam sleeve to the left thumb as tolerated, to be removed for skin checks and hygiene. The order was both discontinued and reordered on 03/20/26, with the clarification that it was to be done three times per day. Review of his range of motion assessment dated [DATE] revealed both hands were contracted. Review of his administration records and progress notes revealed no documentation of the foam sleeve being applied or attempted on any date. Review of his point of care charting revealed six instances…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, observations, resident interview, staff interviews, and facility policy review, the facility failed to clearly distinguish, document and implement fall interventions to decrease the risk of falls. This affected one resident (#33) of one reviewed for falls. The facility census was 112.Findings include:Review of the medical record for Resident #33 revealed she was readmitted to the facility on [DATE], after a fall with a major injury, with diagnoses that included Alzheimer's disease, fracture of the right clavicle, and multiple fractures of left side ribs. Resident #33 was initially admitted on [DATE] with diagnoses of difficulty in walking, weakness, and fracture of radial styloid.Review of the care plan dated 04/28/25 revealed Resident #33 was at risk for falls related to a history of falls and fall related fractures with interventions that included keeping call light within reach and/or call light at hip level when in bed and within reach when in chair.Review of the progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of safety data sheets (SDS), and review of facility policy, the facility failed to ensure personal care items, which could cause harm if consumed, were out of reach of residents who were cognitively impaired and residing in the facility's memory care unit. This affected five residents (#6, #7, #49, #58, and #90) and had the potential to affect 19 residents who the facility identified who have cognitive impairment and were independently mobile. The facility identified one resident (#82) who resided on the memory care unit as being immobile. The facility census was 112. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease, and fatigue. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/19/24, revealed Resident #49 was rarely/never understood and required partial/moderate assistance to walk ten feet. Observation of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure residents had accurate advance directive orders in place throughout their medical record and implement the facilities advance directive policy. This affected two (Residents #4 and #109) of 33 residents reviewed for advance directives. The facility census was 112. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure and fracture of the fibula. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of the physician's orders for Resident #4 revealed an order dated 02/06/25 for a Do Not Resuscitate Comfort Care Arrest (DNRCCA) (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure the residents had activities to meet their needs, especially on the weekends and evenings. This affected two (Residents #20 and #51) of two residents reviewed for activities. The facility census was 112. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted [DATE] with diagnoses including legal blindness, anxiety disorder and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 exhibited intact cognition. Review of the activity care plan dated 02/03/25 revealed Resident #20 was at risk for social isolation and low activity participation related to blindness and periods of confusion. Interventions dated 02/03/25 included interviewing the resident about past roles, monitor for activity needs, room greetings, respect the resident's preferences and offer to read the daily activity flyer in the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of facility policy, and staff interview, the facility failed to ensure Resident #55's oxygen humidification was labeled and dated and Resident #68's oxygen tubing was changed and dated per facility policy. This affected two (Residents #55 and #68) of three residents reviewed for respiratory therapy. Findings include: 1. Review of Resident #55's medical record revealed the resident was admitted on [DATE] with diagnoses including heart failure, hypertensive heart disease with heart failure and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment. Review of Resident #55's respiratory care plan dated 01/25/23 revealed an intervention dated 05/08/23 to administer oxygen as ordered and keep head of bed elevated due to shortness of breath when lying flat. Review of Resident #55's physician orders revealed an order dated 05/25/23 for oxygen therapy per nasal cannula at two liters continuous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the physician was notified and responded timely to Resident #116's complaints of pain following a fall. This finding affected one (Resident #116) of three residents reviewed for falls. Findings include: Review of Resident #116's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and essential tremors. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #116's fall Incident form dated 11/11/24 at 7:50 P.M. revealed Certified Nursing Assistant (CNA) #918 reported she saw the resident in the Centrum (main television lounge area) when she saw the resident stand up and attempt to walk. Before she could reach her, the resident had fallen on the floor and landed on her right side. The alarm was present in the wheelchair and alarming. CNA #918 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, policy review and staff interview, the facility failed to ensure resident re-weights were obtained to verify accuracey of weight changes per facility policy. This affected one (Resident #101) of five residents reviewed for nutrition. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record including weight recording identified on 03/26/22 the resident's weight was 280.4 pounds. The next weight recorded on 04/14/22 was 286.8 pounds, a difference of 6.4 pounds from the prior weight. On 04/28/22 the weight recorded was 293.8 pounds, a difference of seven pounds from the prior weight. On 05/07/22 the weight recorded was 279.6 pounds, a difference of 14.2 pounds from the prior weight. On 05/14/22 the weight recorded was 286.6 pounds, a difference of seven pounds from the prior weight. On 05/21/22 the weight recorded was 284.6 pounds. On 07/02/22 the weight recorded was 274.6 pounds, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview the facility failed to ensure hospice records including certification, assessments and visitation notes were available to the facility staff for collaborative care and services to Resident #101. This affected one (Resident #101) of two residents reviewed for hospice services. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record revealed a physician's order dated 08/05/22 to admit the resident to hospice services by Southern Hospice. Further review of the medical record including paper medical chart in the nursing office found no evidence of any type of hospice certification paperwork, hospice assessments or hospice visitation notes. Interview with Unit Secretary #504 on 09/01/22 at 9:45 A.M. verified there was no evidence of any hospice certification paperwork, assessments and/or visitation notes in the resident's medical record or a separate binder located…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.