Crandall Nursing Home

In the surveyor’s words

From the most serious findings on record at Crandall Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 15, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, review of a self-reported incident (SRI), and interview, the facility failed to ensure Resident #54 was safely transferred in a mechanical lift to prevent fall with major injury. Actual harm occurred on 12/15/25 at approximately 1:10 P.M. when Resident #54, who was cognitively impaired and dependent on staff to transfer, sustained a fall from a mechanical lift device during a staff assisted transfer that resulted in a subarachnoid hemorrhage (brain bleed), which the hospital physician noted had the potential to be a serious and life-threatening condition. […]

• Actual harm, isolatedF689Feb 8, 2021

  Based on interview, record review, and review of a Self Reported Incident (SRI) the facility failed to ensure resident safety during transport. Actual Harm occurred on 01/29/21 when State tested Nurse Aide (STNA) #300 failed to apply a seat belt during transport and Resident #1 was thrown from his wheelchair when STNA #300 had to stop suddenly. This resulted in a fractured nose, bruises and skin tears to Resident #1. This affected one (Resident #1) of five residents interviewed for safety/falls. (Residents #1, #2, #3, #4 and #5). The facility census was 104. Findings include: Review of the medical record for the Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. He was taking Eliquis, an anticoagulant which increased the risk of bleeding and bruising. […]

• No harm, potential for more than minimal, patternF689Mar 20, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF550Mar 24, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF688Mar 24, 2026

  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. […]