Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Crowell Nursing Center during CMS and state inspections, most recent first.
Improper Food Storage and Temp Log Monitoring: Surveyors found multiple refrigerated and frozen food items that were unlabeled, undated, or past use-by dates, including soup, lettuce, BBQ sauce, peppers, pepperonis, cream, cheese, and sliced turkey. In the prep area, cereal boxes were open to air and shelving was sticky. The temp log binder showed no refrigerator or freezer checks documented since the prior month, and the DM stated staff were responsible for labeling, dating, covering, and monitoring food storage temps.
A resident with dysphagia, aphasia, weakness, and severely impaired cognition was served a pureed breakfast that differed from the regular diet meal served to nearby residents. The pureed meal included pureed scrambled eggs, pureed biscuits, and pureed oatmeal, while other residents received cheese and sausage bake, biscuits, and oatmeal. The RD stated the pureed version was less appealing to the eye, and the resident said she liked sausage and would like it with breakfast if offered.
A resident with intact cognition, COPD, heart disease, and mental health diagnoses was identified as an independent smoker and low elopement risk, but he was allowed to know and use the door code to access the smoking patio. Staff confirmed residents were not supposed to have door codes, yet the resident learned the code by observing staff and had not been formally educated about not sharing it or allowing others to exit.
A resident with moderate cognitive impairment and hospice services had cephalexin listed as an allergy in the chart, yet was ordered and given cephalexin for a UTI for 14 days. Staff later stated the resident had taken the medication before and the reaction was believed to be a side effect rather than a true allergy, but the discussion was not documented and the allergy entry was not updated.
Menu Not Followed for Residents on Pureed Diets: Three residents on pureed diets with dysphagia and severe cognitive impairment were observed receiving plain applesauce in the original container instead of the recipe-based cinnamon applesauce or the pureed dessert option listed on the menu. Staff stated the recipe was not followed as written, and the DM and RD confirmed the dessert should have been prepared and served differently.
Hand hygiene was not maintained during incontinent care for a severely cognitively impaired resident with bowel and bladder incontinence, dementia, aphasia, and muscle weakness. A CNA removed gloves after cleaning the resident, did not wash hands, then put on new gloves and applied a new brief. The CNA later acknowledged the missed handwashing, and the ADON and DON stated staff were trained to wash hands when removing gloves and before donning new gloves; the facility policy also stated gloves do not replace hand hygiene.
A resident with severe cognitive impairment developed a significant lesion on her cheek, which the facility failed to document and address according to physician orders. Despite a care plan in place, weekly skin assessments were not properly documented, and the lesion was not mentioned in key health records. Interviews revealed staff uncertainty in performing and documenting assessments, leading to gaps in care. The resident's family initially refused further evaluation, but later sought treatment as the lesion worsened.
The facility failed to maintain a safe and sanitary environment for three residents, leading to potential risks of pests and foodborne illness. A resident's refrigerator contained expired and unlabeled food, while two residents had personal snacks not stored in sealed containers. Additionally, one resident's refrigerator lacked a thermometer. Staff interviews revealed inconsistencies in responsibilities for cleaning and monitoring resident refrigerators, contrary to facility policy.
Two residents in a LTC facility had inaccurate MDS assessments, leading to potential care risks. One resident's smoking habit was not documented, while another's facial lesion was omitted from the assessment. The MDS LVN acknowledged these oversights, which were contrary to facility policy requiring accurate resident assessments.
A facility failed to conduct a timely smoking assessment for a resident, as required by their policy. The resident, who was cognitively intact and had multiple health conditions, had not been assessed since September 2024, despite the policy requiring quarterly evaluations. This oversight was acknowledged by the LVN, MDS Coordinator, and ADON, highlighting a lapse in ensuring the resident's safety while smoking.
A facility failed to accurately document a treatment order for a resident's skin lesion, entering it for the left cheek instead of the right. The resident, with severe cognitive impairment and multiple health issues, had a lesion on the right cheek that was not properly recorded in the MDS. Staff interviews revealed that nurses were responsible for EHR entries, and the ADON admitted to possibly confusing the lesion's location.
The facility failed to train a staff member on abuse, neglect, exploitation, and misappropriation of resident property, as required by their policy. The staff member's file lacked records of such training, and the Administrator could not provide evidence of training from another facility where the staff member worked full-time. This deficiency could place residents at risk due to untrained staff.
Improper Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. On observation of the refrigerator, surveyors found a 1/2 gallon container of chicken noodle soup that was not labeled or dated, 2 packages of lettuce with a use-by date of 03/16/2026, a gallon container of BBQ sauce with an open date of 03/25/2026 and no use-by date, 4 green peppers that were soft and wilted and not labeled or dated, a bag of pepperonis that was not labeled or dated, a bag of yellow cream that was not labeled or dated, a package of cheese that was opened with a preparation date of 03/16/2026 and no use-by date, and a package of sliced turkey meat with a use-by date of 03/26/2026. In Freezer 2, surveyors observed 10 packages of sliced turkey with a use-by date of 03/26/26. In the kitchen preparation area, surveyors observed three boxes of cereal open to air with no date on the boxes, and the shelving surface was sticky to the touch. Review of the temperature log binder for the refrigerator and freezers showed no documented temperature checks recorded since 03/25/2026. Facility staff stated that it was everyone's responsibility to ensure food items were labeled, dated, covered, and stored properly, and that expired food should be discarded. The DM stated she was responsible for ensuring refrigerator and freezer temperatures were monitored and logged daily and for ensuring staff complied with labeling and dating requirements. Facility policy required refrigerator and freezer temperatures to be checked and logged at least twice daily, and required refrigerated, frozen, and dry storage items to be properly labeled, dated, sealed, and rotated.
Unequal Breakfast Service for Resident on Pureed Diet
Penalty
Summary
The facility failed to treat each resident with respect and dignity and to care for each resident in a manner that promotes quality of life for 1 of 3 residents who received pureed food, Resident #30. Resident #30 was an [AGE]-year-old female admitted with diagnoses including dysphagia, aphasia, and weakness. Her MDS assessment showed a BIMS score of 04, indicating severely impaired cognition, and her care plan and active orders reflected a pureed diet with no restrictions. On observation, the pureed breakfast served to Resident #30 consisted of pureed scrambled eggs, pureed biscuits, and pureed oatmeal, while residents on a regular diet in the dining room were served cheese and sausage bake, biscuits, and oatmeal. The Dietary Regional Director stated the pureed breakfast was not the same as the regular diet because it was less appealing to the eye, and the RD stated residents receiving a pureed diet not receiving the same meal items as residents receiving a regular diet could negatively impact the resident and make them feel less valued. Resident #30 stated she liked sausage and would like to have it with breakfast if it was offered.
Resident Allowed Access to Door Code for Smoking Area
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for Resident #35, who was allowed to have the code for the door when going out to smoke. Resident #35 was a [AGE]-year-old male admitted with diagnoses including acute respiratory failure with hypoxia, COPD, heart disease, tobacco use, paranoid schizophrenia, generalized anxiety disorder, and major depressive disorder. His quarterly MDS showed a BIMS of 13, indicating intact cognition, and he was independent with bed mobility, transfers, walking, and dressing, while requiring supervision or set-up assistance with eating, showering, and personal hygiene. His smoking assessment identified him as an independent smoker, and his elopement/wandering risk assessment identified him as low risk with no elopement-related care plan interventions initiated. The care plan addressed smoking and stated he was a safe smoker who did not require an apron or direct staff supervision during smoking breaks, but it did not address access to door codes, education about door security, or risks associated with unsupervised exit. During observation, Resident #35 entered the code himself to allow access to the patio smoking area. Staff interviews confirmed that residents were not supposed to have door codes, but Resident #35 knew the code by observing staff enter it and had not been formally educated not to share it or allow other residents to exit. The DON stated that neither Resident #35 nor any other residents were supposed to have the door codes and that there was no documentation showing he was authorized to have the code or had received education regarding its use.
Cephalexin Given Despite Documented Allergy
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administration of drugs and biologicals for one resident reviewed for pharmacy services. The resident’s clinical record documented an allergy to cephalexin, with the allergy listed in the profile as of 01/20/26, and the care plan identified the resident as being at risk for adverse reactions to cephalexin with interventions to verify allergies before medication administration and update the allergy list as needed. The resident had a BIMS score of 10 out of 15, required extensive assistance with multiple activities of daily living, and was receiving hospice services. Despite the documented allergy, the resident was ordered cephalexin 500 mg orally for a UTI and received the medication daily for 14 days from 03/20/26 through 04/02/26. The resident stated she had taken cephalexin recently for a UTI, was not allergic to it, and had no issues while taking it. Staff interviews confirmed the medication was administered after discussions with the ADON and hospice nurse, who believed the listed allergy was not a true allergy and may have been a side effect, but those conversations were not documented and the allergy information was not updated or removed from the record.
Menu Not Followed for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure the menu was followed for 3 residents who received pureed diets: Resident #7, Resident #16, and Resident #30. Record review showed each resident had diagnoses including dysphagia and aphasia, and each had orders and care plans directing that a pureed texture diet be provided and served as ordered. The kitchen recipe book included a recipe for Cinnamon Applesauce that called for applesauce and cinnamon to be mixed thoroughly, and also included an Apple Crisp recipe with instructions for regular and pureed diets. During an observation in the dining room, the three residents were served pureed meals and were given a plastic container of plain applesauce for dessert, while other residents were served apple crisp. Staff stated the applesauce was given because the apple crisp could not be pureed, and one staff member said she was supposed to follow the recipe as written but did not realize the applesauce needed added cinnamon. The DM stated the residents should have had apple crisp or cinnamon mixed with the applesauce and that it should have been served in a bowl rather than in the original container. The RD also stated residents receiving a pureed diet should have received applesauce with cinnamon and that it should have been served in a bowl rather than in the original container.
Hand Hygiene Not Performed During Incontinent Care
Penalty
Summary
Failure to maintain an infection prevention and control program was identified when CNA C did not wash her hands during incontinent care for a resident with bowel and bladder incontinence. Resident #26 was an [AGE] year-old female with diagnoses including dementia, muscle weakness, aphasia, and a history of cerebral infarction. Her quarterly MDS assessment showed a BIMS of 06, indicating severe cognitive impairment, and she required substantial to maximal assistance with toileting hygiene. She was also frequently incontinent of urine and bowel, and her care plan identified her as being incontinent of bowel and bladder related to cognitive impairment secondary to dementia. During observation, CNA C performed incontinent care with CNA D assisting. CNA C washed her hands and donned new gloves, cleaned the resident’s perineal area, assisted with turning the resident, and then cleaned the rectal and buttocks area. After removing dirty linens, CNA C removed her gloves but did not wash her hands before putting on new gloves and applying a new brief. CNA C later acknowledged she should have washed her hands at that point, and CNA D stated staff could use hand sanitizer between glove changes if needed. The ADON and DON stated they trained staff on hand hygiene and expected handwashing when removing gloves, before placing new gloves, or when gloves become soiled. The facility policy stated gloves do not replace hand hygiene and included hand hygiene when moving from a contaminated body site to a clean body site.
Failure to Document and Address Resident's Skin Lesion
Penalty
Summary
The facility failed to ensure that Resident #38 received appropriate treatment and care according to physician orders and the resident's preferences and goals. The facility did not document physician-ordered weekly skin assessments for a lesion on the resident's right cheek, which was a critical oversight given the lesion's progression. Despite the presence of a care plan that included monitoring for signs of infection or complications, the facility did not adequately document or communicate changes in the resident's skin condition. Resident #38, an elderly female with severe cognitive impairment and multiple diagnoses, including dementia and anorexia, was admitted to the facility with a dry, flaky patch on her right cheek. Over time, this lesion developed into a significant open sore. The facility's records showed inconsistencies and omissions in documenting the lesion's condition and the skin assessments that were supposed to be conducted weekly. The lesion was not mentioned in the resident's Minimum Data Set (MDS) or in the Monthly Nurse Summaries, and there was a lack of detailed documentation in the resident's electronic health record (EHR). Interviews with facility staff revealed a lack of confidence and clarity in performing and documenting skin assessments. Nurses often relied on the Assistant Director of Nursing (ADON) and Director of Nursing (DON) to verify and document their findings, leading to gaps in the resident's care records. The resident's family member initially refused further medical evaluation for the lesion, but later expressed a willingness to seek treatment. However, by this time, the lesion had significantly worsened, and the facility was faced with the challenge of finding a specialist willing to treat the resident. The facility's failure to document and address the lesion in a timely manner placed the resident at risk of harm due to untreated health issues.
Failure to Maintain Safe and Sanitary Food Storage
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for three residents, leading to potential risks of pests and foodborne illness. Resident #26's personal refrigerator contained expired and unlabeled food items, including a bottle of ketchup past its expiration date, a cup with a partially eaten donut, and a bowl with banana pudding showing signs of spoilage. Despite the facility's policy requiring staff to monitor and clean resident refrigerators, Resident #26 reported that staff only checked the temperature and did not clean out the refrigerator. Resident #31, who had moderately impaired cognition and impaired visual function, was observed with an opened bag of tortilla chips on her nightstand, which was not stored in a sealed container as required by facility policy. The resident stated that staff had not advised her to keep the chips in a sealed container, indicating a lack of staff intervention in ensuring compliance with food storage policies. Resident #38, with severely impaired cognition and requiring substantial assistance with activities of daily living, had an open container of cookies and a refrigerator without a thermometer, contrary to facility policy. Interviews with staff revealed inconsistencies in responsibilities for cleaning and monitoring resident refrigerators, with some staff indicating that it was a shared responsibility, while others mentioned specific roles. The facility's failure to adhere to its policies on food storage and refrigerator maintenance posed a risk of bacterial infection and pest control issues for the residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks in their care. Resident #3, a smoker, had an annual Minimum Data Set (MDS) assessment that did not reflect his tobacco use. Despite having a care plan that acknowledged his smoking habits and the associated risks, the MDS inaccurately indicated no tobacco use. This oversight was acknowledged by the MDS Licensed Vocational Nurse (LVN) during an interview, who admitted to missing this critical information. Resident #38 had a lesion on her right cheek that was not documented in her quarterly MDS assessment. Her medical records and care plan noted the presence of a dry, flaky patch on her cheek, which later developed into a large open wound. Despite this, the MDS assessment failed to record the lesion, which was observed by staff and family members. The Assistant Director of Nursing (ADON) and the MDS LVN both acknowledged the inaccuracy, with the LVN stating that the lesion was not noticed during the assessment process. The facility's policy on MDS completion requires comprehensive and accurate assessments, as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. However, the failure to accurately document the residents' conditions in the MDS assessments could lead to inadequate care and treatment. The MDS LVN's reliance on informal communication and the lack of thorough documentation contributed to these deficiencies, which were identified during the survey process.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards for a resident who was a smoker. The resident, a cognitively intact male with multiple health conditions including chronic obstructive pulmonary disease and generalized anxiety disorder, had not received a smoking assessment since September 2024, despite facility policy requiring such assessments quarterly. This oversight was confirmed during interviews with the LVN Charge Nurse, the MDS Coordinator, and the ADON, who all acknowledged that the smoking assessment was overdue and not completed as per policy. The MDS Coordinator and the ADON both indicated that the smoking assessments are crucial for determining a resident's ability to smoke safely, especially if there is a decline in cognitive or mobility function. The facility's smoking policy, revised in July 2023, mandates that smoking evaluations be conducted upon admission and quarterly. The failure to conduct the required assessment could potentially place residents at risk for accidents, such as burns or other injuries, due to a lack of updated evaluation of their smoking capabilities.
Inaccurate Medical Record Entry for Resident's Skin Lesion
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the entry of a treatment order for a skin lesion. The order for applying barrier cream was incorrectly documented in the electronic health record (EHR) as being for the resident's left cheek, while the lesion was actually located on the right cheek. This discrepancy was identified during a review of the resident's medical records, which included progress notes and medication administration records (MAR). The error in documentation could potentially lead to the resident receiving incorrect treatment. The resident involved was an elderly female with multiple diagnoses, including protein-calorie malnutrition, unspecified dementia, cognitive communication deficit, muscle wasting, and anorexia. The resident's cognitive impairment was severe, as indicated by a BIMS score of 3. Despite the presence of a lesion on the right cheek, the quarterly Minimum Data Set (MDS) did not document this condition, and the care plan noted a preference for no treatment at the time. Interviews with facility staff revealed that nurses were responsible for entering orders into the EHR, and the Assistant Director of Nursing (ADON) admitted to possibly confusing the location of the lesion when entering the order.
Failure to Train Staff on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to provide necessary training to their staff on abuse, neglect, exploitation, and misappropriation of resident property, as well as the procedures for reporting such incidents. This deficiency was identified during a review of the employee file for one staff member (ST) out of 15 employees reviewed for staff training. The employee file revealed a hire date of September 13, 2023, but lacked any record of training on the aforementioned topics. This oversight in training could potentially place residents at risk of injury or harm due to being cared for by untrained staff. During an interview, the Administrator (ADM) acknowledged that ST worked full-time at another facility and only occasionally at this facility. The ADM stated that ST was trained at the other facility but could not provide any records of such training. The facility's policy, dated November 29, 2022, mandates the development, implementation, and maintenance of an effective training program for all staff, including training on abuse, neglect, and exploitation prevention. The failure to adhere to this policy was noted as a deficiency in the facility's training program.
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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 Crowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehabilitation And Healthcare Of Vernon | 26.5 mi | ★★★★★ | 0 | 0 |
| Vernon Rehabilitation And Nursing Center | 26.6 mi | — | 0 | 0 |
| Munday Nursing Center | 37 mi | ★★★★★ | 0 | 0 |
| Seymour Rehabilitation And Healthcare | 37.1 mi | ★★★★★ | 1 | 0 |
| Avir At Knox City | 39.7 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.