Crowell Memorial Home

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 18, 2026

  Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions identified on the care plan to prevent falls for 3 (Resident 1, 2 and 4) of 4 residents sampled. The facility census was 77. Findings are:Record review of the facility's undated policy titled Fall Prevention Program revealed the following:-each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]

• Actual harm, isolatedF760Dec 14, 2023

  Based on interview and record review, the facility failed to ensure residents were free from significant medication error for 1 (Resident 3) of 3 sampled residents. The facility had a total census of 59 residents. Findings are: Record review of Resident 3's undated Face Sheet revealed, the resident was admitted to the facility with a diagnosis of chronic kidney disease and unspecified dementia. A review of Medication Error Report dated 11/27/23 revealed, Resident 3's Lasix 80 mg one time per day was held on 11/21/23, 11/22/23, and 11/23/23. […]

• Actual harm, isolatedF684Jul 26, 2023

  Licensure Reference Number NAC 12-006.09D Based on interview and record review the facility failed to; identify, assess, and obtain treatment for head injury for 1 resident (Resident 1) of 4 residents reviewed. The facility staff identified a census of 62. Findings are: A. Record review of the facility Policy and Procedure for Accidents and Incidents dated 9-2022 revealed the following information: -Protocol: -1. The facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident). -2. The facility defines an accident/incident as an event, occurrence, or happening that may produce actual or potential undesirable outcome. -3. […]

• Actual harm, isolatedF686Mar 1, 2021

  LICENSURE REFERENCE NUMBER 175NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to complete weekly skin monitoring and implement interventions to prevent the development of pressure ulcers for 1(Resident 2) of 4 sampled residents. The facility staff identified a census of 51. Findings are: Record review of Resident 2's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2-04-2021 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 12. […]

• Actual harm, isolatedF689Mar 1, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7B Based on observation, record review and interview; the facility staff failed to implement interventions to prevent additional falls for 1 (Resident 16) and failed to implement interventions to safely transfer a resident when using a mechanical lift for 1 (Resident 10) of 10 residents. The facility staff identified a census of 51. Findings are: A. Record review of Resident 16's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-04-2020 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) score was an 11. According to the MDS Manuel a score of 8 to 12 indicated moderately impaired cognition. […]