Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crandall Nursing Home during CMS and state inspections, most recent first.
Dining trays were not delivered together for three residents who were seated at the same table for lunch. One resident received a tray first, while two others waited as staff continued passing trays to residents in rooms; an LPN stated the trays had not arrived and that meal trays take a long time to be delivered. One resident did not receive a tray until after the first resident had finished eating and left the table, and the Administrator verified the residents did not experience dignity while dining.
A resident with cerebral infarction, Parkinson's disease, Lewy body neurocognitive disorder, and dementia had an order for a foam sleeve to the left thumb, but chart review found no documentation that it was applied or attempted. Surveyors observed the resident's left hand contracted with no sleeve in place, and RN and DON interviews confirmed the ordered intervention was being left off without specific documentation explaining why.
A resident with Alzheimer's disease, severe cognitive impairment, and a history of fall-related fractures had inconsistent fall interventions documented after multiple falls, including a major injury with rib fractures. The record alternated between no interventions, supervision with ambulation, and the falling star protocol, while observations showed the call light out of reach, no ambulatory device present, and no staff monitoring as the resident repeatedly stood up and moved around. The Administrator confirmed clear fall interventions were needed, but the chart did not reflect a consistent plan.
A cognitively impaired, fully dependent resident with a history of falls and an order and care plan for mechanical lift use for all transfers was being transferred from a chair to bed by two CNAs using a mechanical lift. During the transfer, one bottom loop of the sling was not properly secured to the lift hook/clip; as the resident was lifted and the chair was moved away, the unsecured loop came off, causing the resident to fall forward to the floor. The resident was found on the floor partially over the lift base with a bleeding forehead laceration, a large lump, finger discoloration, and non-verbal signs of pain, and was later diagnosed in the ED with a subarachnoid hemorrhage. Witness statements, hospital records, and the facility’s SRI investigation all documented that the fall occurred from a mechanical lift at its highest setting due to the sling loop coming off the hook, while the incident report and nurse’s note did not state that the fall was from a mechanical lift. Facility leadership acknowledged in interviews that the event was due to human error and failure to ensure the sling loop was properly secured before initiating the lift, contrary to the facility’s lift and fall prevention policies.
A facility failed to keep hazardous personal care items out of reach of cognitively impaired residents in the memory care unit. Observations revealed that items like air fresheners, isopropyl alcohol, and body mists were accessible in residents' rooms, contrary to facility policy. The Memory Care Director confirmed these items should have been stored securely. The facility's policy required daily inspections to prevent such safety concerns, but the presence of these items indicated a lapse in policy adherence.
The facility failed to maintain accurate advance directive orders for two residents. One resident had conflicting DNR statuses between their electronic and hard medical records, while another resident's DNRCCA status was not reflected in the physician orders. These discrepancies were confirmed by staff interviews, highlighting a failure to implement the facility's advance directive policy.
The facility failed to provide adequate activities for residents, particularly on weekends and evenings, affecting two residents at risk for social isolation. Activity calendars showed gaps in scheduled activities, and the activities director confirmed limited weekend and evening programs, contrary to the facility's policy.
Two residents in a facility experienced deficiencies in respiratory care due to improper labeling and dating of equipment. One resident had an unlabeled oxygen humidifier, while another had outdated oxygen tubing, contrary to facility policy requiring weekly changes. These issues were confirmed by LPNs during observations.
A resident with moderate cognitive impairment fell in the facility's common area and later reported hip pain. Despite the resident's complaints, the on-call service instructed staff to wait until morning to contact the physician. An X-ray the next day revealed a hip fracture, leading to the resident's transfer to the emergency department. The delay in physician notification and response was identified as a deficiency.
Dining trays were not delivered together, affecting resident dignity
Penalty
Summary
The facility failed to maintain dignity while dining for three residents who were dependent on staff for ADLs and had severe cognitive impairment. Resident #85 had diagnoses including dysphagia, major depressive disorder, and a cardiac pacemaker, with a BIMS score of 7. Resident #88 had diagnoses including orthopedic aftercare, a right femur fracture, and nocturia, with a BIMS score of 4. Resident #93 had diagnoses including paroxysmal atrial fibrillation, anorexia nervosa, and hypertension, with a BIMS score of 6. On observation, Residents #85, #88, and #93 were seated together at a table in the main common area near the nursing station for lunch, but only Resident #88 initially had a tray. Residents #85 and #93 remained without lunch trays while staff continued delivering trays to other residents eating in their rooms. A CNA stated that Resident #88's tray arrived before the others and that the remaining trays would come with the next meal cart. A later observation showed a second meal cart arrive without trays for Residents #85 and #93, and an LPN stated their trays had not arrived and that meal trays take a long time to be delivered. Resident #85 eventually received a tray after Resident #88 had finished eating and left the table, while Resident #93 still had not received a tray at that time. The Administrator later verified that Residents #85, #88, and #93 did not experience dignity while dining because their lunch trays were not delivered at the same time.
Failure to Provide Ordered Thumb Mobility Intervention
Penalty
Summary
The facility failed to provide ordered mobility interventions for Resident #10, who was admitted with diagnoses including cerebral infarction, Parkinson's disease, neurocognitive disorder with Lewy bodies, and dementia. The resident's orders included wearing a foam sleeve to the left thumb as tolerated, removed for skin checks and hygiene, and later clarified to be done three times per day. The resident's range of motion assessment showed both hands were contracted. Review of administration records, progress notes, and computer charting revealed no documentation that the foam sleeve was applied or even attempted on any date, although point of care charting showed six instances from 03/20/26 to 03/23/26 where the foam sleeve was documented as reviewed. Surveyor observations on 03/23/26 at 8:59 A.M. and 3:08 P.M. showed the resident did not have any sleeve on the left thumb. The left hand was contracted into a fist with the thumb pressed between the fore and middle fingers, and a foam dressing was resting on top of the middle finger between it and the thumb. The resident was not interviewable. RN #306 stated the resident was uncomfortable when too much was placed between the fingers and needed the foam dressing to treat a moisture injury, and that the ordered cloth sleeve was being left off because the foam dressing accomplished the goal of preventing the thumb from pressing down on the middle finger. The DON and RN #306 confirmed there was no specific documentation that the ordered cloth sleeve had been applied and no notes explaining why it was not applied.
Inconsistent fall interventions and lack of supervision for a resident with repeated falls
Penalty
Summary
The facility failed to clearly distinguish, document, and implement fall interventions for a resident with a history of falls and fall-related fractures. Resident #33 was readmitted after a fall with major injury and had diagnoses including Alzheimer's disease, a right clavicle fracture, and multiple left rib fractures. The care plan identified fall risk and included keeping the call light within reach or at hip level, but the resident's record later showed conflicting fall interventions, including documentation that a fall was an isolated incident with no interventions, then later supervision with ambulation, and later the falling star protocol. The resident's MDS showed severe cognitive impairment with a BIMS score of six and need for supervision or touching assistance with walking and transfers. Observations on 03/23/26 showed Resident #33 seated on the edge of her bed with the call light approximately six feet away wrapped around a lamp shade and not within reach, no ambulatory devices present, and no staff monitoring the resident. The resident appeared confused and repeatedly performed sit-to-stand transfers. A CNA confirmed the resident was confused, a fall risk, and frequently stood up, sat down, and walked back and forth, and also verified the call light was out of reach and the resident was not being monitored with the door closed. The Administrator confirmed the resident had a fall with major injury resulting in fractured ribs and required clear fall interventions. The facility's fall policies stated interventions would be reviewed, discussed, documented, and put into place as indicated, but the record did not reflect a clear fall intervention to prevent future falls.
Improper Mechanical Lift Transfer Leading to Resident Fall and Brain Bleed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively impaired, fully dependent resident was safely transferred using a mechanical lift, resulting in a fall with major injury. The resident had Alzheimer’s disease, dementia, a history of falling, abnormal posture, poor vision, and overall debility, and was care planned and ordered for mechanical lift use for all transfers. The resident’s ADL and fall care plans identified impaired ability to perform ADLs, high fall risk, confusion, impaired safety awareness, impaired mobility, and poor vision, with interventions including use of a mechanical lift for all transfers and maintaining a safe environment. Despite these identified needs and interventions, the resident experienced a fall during a staff-assisted mechanical lift transfer. On the date of the incident, two CNAs were transferring the resident from a chair to bed using a mechanical lift. Witness statements from both CNAs indicated that during the transfer, one of the sling’s bottom loops/straps was not properly secured to the hook/clip on the lift. One CNA reported that as they lifted the resident into the air and moved to remove the chair from underneath, she noticed the loop had come off the hook, and before staff could react, the resident fell forward to the floor. The other CNA similarly stated that as the resident was lifted, the strap came unclipped and the resident went forward onto the floor. The facility’s investigation of the self-reported incident documented that the left bottom loop of the sling came out of the hook on the lift during the transfer, causing the resident to fall and strike her head. Following the fall, the resident was found lying on her back on the floor with her legs and left upper body over the bottom of the lift device, with visible bleeding from an open area on the left side of the forehead and a lump approximately five centimeters in circumference. The resident also had deep purple discoloration to the right second finger and displayed non-verbal indicators of pain, such as facial grimacing, but was unable to verbalize pain due to severe cognitive impairment and being rarely or never understood. The nurse’s incident documentation and nurse’s note replicated the description of the resident’s position and injuries but did not state that the resident had fallen from a mechanical lift during a transfer. The resident was sent to the emergency department, where hospital records documented that she had fallen from a mechanical lift that was at its highest setting at the time of the fall, and a CT scan revealed a subarachnoid hemorrhage (brain bleed). Facility leadership, including the Administrator and DON, later acknowledged in interviews that the fall was due to human error, specifically that staff did not ensure the sling loop was properly secured before initiating the lift, and that the incident occurred during a mechanical lift transfer. The facility’s written policies for Invacare lift use required two staff to operate the lift, mandated that slings be hooked to the lift with hooks facing outward/away from the resident, and assigned responsibility to nursing aides to monitor slings for rips, holes, fraying, or other concerns with every use. The fall prevention policy required completion of an incident report by the nurse, timely notification of the physician and family, discussion of the incident in morning report, and implementation of interventions as indicated, including referral for staff education or discipline if employee work performance was implicated. In this incident, although two staff were present, the sling loop was not properly secured to the lift hook before the resident was raised, and the incident report and nurse’s note did not document that the fall occurred from a mechanical lift during a transfer, despite this being reported in witness statements, hospital documentation, and the facility’s own SRI investigation.
Failure to Secure Hazardous Personal Care Items in Memory Care Unit
Penalty
Summary
The facility failed to ensure that personal care items, which could cause harm if consumed, were kept out of reach of residents who were cognitively impaired and residing in the memory care unit. This deficiency was identified through observations, staff interviews, medical record reviews, and safety data sheet (SDS) reviews. The facility's memory care unit housed residents with severe cognitive impairments, including those with dementia and Alzheimer's disease, who were independently mobile. The presence of potentially harmful personal care items in residents' rooms posed a risk to these individuals. During observations, it was noted that several residents' rooms contained personal care items such as air fresheners, isopropyl alcohol, nail polish remover, aftershave, and body mists, all labeled with warnings to keep out of reach of children. These items were found on open shelving and bedside tables, easily accessible to residents. Interviews with the Memory Care Director confirmed that these items should not have been visible or accessible to residents, and there were provisions for storing such items securely in locked drawers. The facility's policy required daily environmental rounds to inspect residents' rooms and bathrooms for safety concerns. However, the presence of these items indicated a lapse in adherence to this policy. The SDS for the products found in the residents' rooms highlighted the potential for skin and eye irritation, respiratory issues, and other health risks if ingested or improperly used, underscoring the importance of keeping these items out of reach of cognitively impaired residents.
Inaccurate Advance Directive Orders for Two Residents
Penalty
Summary
The facility failed to ensure that residents had accurate advance directive orders in place throughout their medical records, affecting two residents. Resident #4 was admitted with diagnoses including heart failure and a fibula fracture and was cognitively intact. The medical record review revealed a discrepancy between the electronic chart, which had a signed Do Not Resuscitate Comfort Care Arrest (DNRCCA) code status, and the hard medical chart, which had a signed Do Not Resuscitate Comfort Care (DNRCC) code status. This inconsistency was confirmed by a staff member during an interview. Resident #109, who was moderately impaired cognitively and had diagnoses including Alzheimer's disease and type two diabetes mellitus, also had discrepancies in their advance directive documentation. The DNR Comfort Care document indicated a DNRCCA status, but there was no corresponding physician order in the medical record. A registered nurse confirmed the absence of a physician order for the DNRCCA status, despite the facility's policy requiring a clearly stated code status, a physician's order, and a completed and signed DNR form for every resident.
Inadequate Resident Activities on Weekends and Evenings
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of its residents, particularly during weekends and evenings. This deficiency affected two residents who were at risk for social isolation and low activity participation due to their medical conditions. One resident, who was legally blind and had anxiety disorder, expressed boredom on weekends due to the lack of activities. Another resident, diagnosed with dementia and schizoaffective disorder, also reported boredom on weekends when no activities were available. The activity care plans for both residents included interventions to monitor activity needs and provide opportunities for engagement, but these were not effectively implemented. The review of the facility's activity calendars for January, February, and March revealed a lack of scheduled activities on certain weekends and evenings. The activities director confirmed that normal evening activities concluded by 4:30 P.M., and weekend activities were limited to movies and church services broadcasted on the in-house TV channel. The facility's activity policy stated that programs should be available daily and designed to meet each resident's needs, but this was not adhered to, as evidenced by the gaps in the activity schedule and the residents' reports of boredom.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper labeling and dating of respiratory care equipment for two residents, leading to deficiencies in their care. Resident #55, who was admitted with heart failure and moderate cognitive impairment, had an oxygen humidifier in use without an open date. This was confirmed by an LPN during an observation. The facility's policy requires that all humidifiers be labeled with the date and time they are opened, but this was not adhered to in this case. Similarly, Resident #68, who has diagnoses including macular degeneration and dementia, was found to have oxygen tubing in use that was labeled with a date from over two months prior. The facility's policy mandates that oxygen tubing be changed weekly by the servicing company, but this was not done. An LPN verified the outdated tubing and confirmed the requirement for weekly changes. These oversights in following the facility's oxygen administration policy resulted in deficiencies in the respiratory care provided to these residents.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification and response to a resident's complaints of pain following a fall. Resident #116, who had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and essential tremors, fell in the Centrum area on 11/11/24 at 7:50 P.M. The resident was observed by a CNA attempting to walk from her wheelchair and subsequently fell on her right side. Initial assessments by the nursing staff did not reveal any immediate injuries or complaints of pain, and the resident was returned to her wheelchair and later to bed. During the night, the resident began to report pain in the right hip/thigh area. Despite this, the on-call service instructed the staff to contact the physician in the morning rather than immediately. It was not until the morning of 11/12/24 that the physician was contacted, and an X-ray was ordered, revealing an acute subcapital hip fracture. The resident was then sent to the emergency department for further evaluation and treatment. Interviews with the Director of Nursing, the resident's daughter, and nursing staff revealed concerns about the delay in addressing the resident's pain and the lack of immediate physician intervention. The facility staff believed they had followed protocol by contacting the on-call service, but the service's refusal to connect them with the physician resulted in a delay in care. The deficiency was investigated under Complaint Number OH00160374.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sebring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bel Air Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Auburn Skilled Nursing And Rehab | 3.7 mi | ★★★★★ | 16 | 0 |
| Altercare Of Alliance Ctr For Rehab & Nc Inc | 5.9 mi | ★★★★★ | 0 | 0 |
| Roselawn Gardens Nursing & Rehabilitation | 6 mi | ★★★★★ | 0 | 0 |
| Mccrea Manor Nsng And Rehab Ctr Llc | 6.2 mi | ★★★★★ | 15 | 0 |
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