Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Crane during CMS and state inspections, most recent first.
The facility did not ensure the Medical Director or a representative attended required quarterly QAPI meetings, as shown by attendance records and staff interviews. The Medical Director attended only one meeting in the past year, despite policy requiring quarterly participation. This failure resulted in the QAPI committee not meeting regulatory requirements for membership and attendance.
Three residents with severe cognitive impairment and dependence on staff were not provided adequate supervision or safe assistance devices. One resident was not assessed or care planned for safe vaping and was found with unsecured vaping devices, while two others were transferred unsafely by staff who did not use gait belts or proper techniques, contrary to facility policy.
Surveyors found that two medication carts contained improperly stored and labeled medications, including undated open insulin pens for two residents with diabetes and bottles with dried drippings. Staff interviews confirmed that insulin pens were not dated as required and medication bottles were not cleaned before storage, contrary to facility policy.
A resident with severe cognitive impairment and a history of dementia was not assessed or care planned for nicotine or vape use, despite possessing vapes and discussing vaping behaviors. Nursing documentation noted an elopement attempt to obtain a vape, but the care plan and assessments did not address these needs, contrary to facility policy requiring individualized plans for residents who smoke or vape.
A resident with severe cognitive impairment, hemiplegia, and a history of malnutrition experienced weight loss and was unable to access the main portion of a meal because staff did not place the plate within reach. Despite care plan interventions for nutritional support, staff failed to notice the issue during the meal, and there was no facility policy to ensure food was accessible to residents needing assistance.
A CNA failed to change gloves and perform hand hygiene after providing perineal care to a resident with severe cognitive impairment and incontinence, then assisted the resident with a clean brief and pants while still wearing contaminated gloves. This action was observed and confirmed to be inconsistent with the facility's infection control and perineal care policies.
A resident with cognitive impairments alleged that a CNA pushed him during a disagreement over a smoke break. The facility conducted an investigation, finding no injuries, but failed to report the investigation results to state officials within the required timeframe. The CNA involved did not return to the facility, and the incident was deemed inconclusive.
The facility failed to notify a resident's representative and physician of changes in the resident's psychosocial status and medication depletion. The resident exhibited aggressive behavior and refused medication multiple times, but the family and physician were not informed in a timely manner, leading to a lapse in care and communication.
The facility failed to provide pharmaceutical services, resulting in a resident missing fifteen doses of Risperidone. The resident, with a history of traumatic brain injury and quadriplegic cerebral palsy, experienced increased aggression and behavioral issues due to the missed medication. Miscommunication between the facility and the family, along with inadequate procedures for obtaining medications, contributed to this deficiency.
The facility failed to ensure residents received adequate supervision to prevent accidents, with water temperatures in shower rooms and resident sinks found to be excessively high. Residents reported the water was too hot, and temperature readings confirmed this, posing a risk of burns. Staff were unaware of the correct temperature range, and maintenance used an inaccurate thermometer, leading to incorrect readings.
The facility failed to honor the smoking preferences of two residents, restricting them to one cigarette per smoke break despite no formal policy supporting this rule. This action was inconsistent with the facility's documented policies on resident rights and self-determination.
The facility failed to maintain a safe, clean, and homelike environment for three residents, with issues including non-functional hot water faucets, missing closet doors, and a malfunctioning sink drain. Residents had reported these issues, but no corrective actions were taken.
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents who were incontinent of bladder. CNAs did not follow proper hand hygiene and peri-care techniques, leading to potential cross-contamination and increased infection risk. Interviews revealed a lack of training and competency checks in peri-care procedures.
The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for three residents. Observations and interviews revealed a lack of necessary assessments, physician orders, and informed consents, putting residents at risk.
The facility failed to conduct annual competency evaluations for four CNAs, potentially leading to inadequate care for residents. The DON admitted to not performing any staff competencies since her hire and was unaware of the requirement for annual evaluations.
The facility failed to ensure that residents with PRN orders for Lorazepam were limited to 14 days, affecting six residents with various diagnoses. The PRN orders had no stop dates, and there was no documented rationale for the continued provision of the medication in the physician progress notes.
The facility failed to ensure the dry food storage was not past their use-by dates, placing residents at risk for foodborne illnesses. Expired packages of marshmallows, shredded coconut, and black-eyed peas were found in the pantry. Both the Dietary Manager and Administrator acknowledged the oversight and the potential negative impact on residents.
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This included not maintaining required hospice forms and documentation, such as the hospice plan of care and certificate of terminal illness, and lacking physicians' orders for hospice care. Interviews revealed a lack of awareness and understanding of the requirement to maintain hospice documentation, potentially leading to inadequate end-of-life care for residents.
The facility failed to ensure that four CNAs received the required minimum 12 hours of annual in-service training. The DON admitted to not conducting any staff in-service competencies since her hiring and was unaware of the training requirements, leading to a deficiency in staff training and potential negative impacts on resident care.
The facility failed to lock a medication cart, leaving it unattended with various medications accessible. RN A admitted to leaving the cart unlocked due to distraction during shift change, and the DON confirmed that all medication carts should be locked when unattended.
A facility failed to obtain a physician's order and consent before placing a resident with severe cognitive impairment in a secure unit. The necessary documentation was missing, and staff admitted the consent form might have been lost, violating the facility's policy.
Failure to Ensure Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, specifically not ensuring the Medical Director or a representative attended at least quarterly QAPI meetings. Record review of attendance sign-in forms for QAPI meetings over the past year showed that the Medical Director attended only one meeting, despite the requirement for quarterly attendance. Interviews with the Administrator and Regional RN Consultant confirmed that the Medical Director's participation was infrequent, and the RN Consultant was unaware of the lack of attendance. The facility's policy required the Medical Director to attend quarterly, but this was not followed. The deficiency was identified through interviews and review of meeting attendance records, which documented the absence of the Medical Director from the majority of QAPI meetings. The Administrator acknowledged that while the Medical Director and Nurse Practitioner were regularly present in the building for resident care, they did not participate in the required QAPI meetings. The facility's QAPI policy, effective since 2017, outlines the responsibility of the Administrator to ensure compliance with regulatory requirements, including the proper composition and functioning of the QAPI committee.
Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. One resident with severe cognitive impairment and a history of elopement was not assessed or care planned for safe vaping. The resident's baseline care plan and assessments did not address nicotine or vaping use, and the resident was found with multiple vapes at his bedside outside of supervised smoking times. Facility policy required all vaping materials to be secured and individualized plans for safe storage and supervision, but these were not implemented for this resident. Two other residents with severe cognitive impairment and dependence on staff for transfers were transferred unsafely by staff. In one case, two CNAs transferred a resident from a shower chair to bed by applying a gait belt too loosely and hooking their arms under the resident's arms, resulting in the resident's weight being supported by her arms rather than her legs. The staff were unaware of the increased risk of injury from this method and did not recognize the resident's non-weight bearing status as requiring a different transfer method. The care plan and Kardex were not updated to reflect the resident's needs, and staff did not follow safe transfer protocols as described by facility leadership. In another instance, two CNAs transferred a resident from a wheelchair to bed by grabbing her under the armpits and by the back of her pants, without using a gait belt. The resident was unable to assist with the transfer, and staff acknowledged that this method could lead to injuries. The staff were not certain of the resident's transfer status and did not have gait belts available at the time of transfer, despite facility policy requiring their use. Observations and interviews confirmed that staff did not follow established safe transfer procedures, and documentation indicated the resident was totally dependent on staff for transfers.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified failures in the facility’s pharmaceutical services related to the labeling, storage, and cleanliness of medications on two medication carts. On the 200 hall medication cart, a bottle of milk of magnesia was found with dried drippings on the lid, and on the 300 hall medication cart, an empty bottle of Pro Stat liquid collagen with dried drippings was observed. Additionally, two open insulin pens for two residents were found undated in the 300 hall medication cart. According to interviews with the DON and nursing staff, insulin pens are required to be dated upon opening, and medication bottles should be cleaned before storage to prevent cross contamination, as per facility policy. The residents involved had significant medical needs, including diabetes mellitus managed with insulin therapy. One resident had a history of Type 2 diabetes mellitus with hyperglycemia and severe cognitive impairment, while another had Type 2 diabetes with complications and diabetic polyneuropathy, also with severe cognitive impairment. Physician orders for both residents included specific insulin regimens. The lack of dating on insulin pens and improper storage of medication bottles were confirmed through observation and staff interviews, indicating non-compliance with facility policy and accepted professional standards for medication management.
Failure to Develop Comprehensive Care Plan for Nicotine Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing nicotine use for a resident with severe cognitive impairment and a history of dementia. Upon admission and re-admission, the resident was not identified as a tobacco user, and no smoking or vaping assessments were completed. The resident's baseline and comprehensive care plans did not address nicotine or vape use, despite facility policy requiring individualized plans for residents who smoke or vape. Multiple observations and interviews revealed the resident possessed vapes at the bedside and discussed vaping, yet these behaviors were not reflected in the care plan or assessments. Nursing notes documented an incident where the resident attempted to elope from the facility to obtain a vape, resulting in the application of a wander guard. Interviews with the DON and Corporate RN confirmed that no assessments or care plans for vaping were present in the resident's record, despite the expectation that such needs would be addressed during the care planning process. Facility policies required the interdisciplinary team to develop individualized plans for safe storage and supervision of smoking materials, but this was not completed for the resident in question.
Failure to Ensure Food Was Accessible to Resident with Nutritional Risk
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with multiple medical conditions, including malnutrition, dementia, hemiplegia, and a history of weight loss. The resident was on a large portion, regular texture diet with specific interventions outlined in the care plan, such as providing fortified cereal, monitoring intake, and offering snacks. Despite these interventions, the resident's weight remained below the recommended Body Mass Index, and a slight weight loss was documented over a two-month period. During a lunch meal observation, the resident was placed in a geri-chair with his functional side against the table, but his main plate was positioned out of reach. The resident was only able to access a salad and not the main components of his meal. Staff, including the DON, did not notice that the plate was out of reach, and the resident verbally expressed hunger and his inability to reach the food. Only after the surveyor moved the plate did the resident begin eating the rest of his meal. The DON later assisted with eating, but the initial lack of access to food was not addressed by staff. Interviews with facility staff revealed there was no policy in place to ensure food was placed within reach of residents. The MDS Coordinator and Regional RN acknowledged the issue, and the VP of Regional Operations stated it was common sense for aides to leave food within reach. The deficiency was further highlighted by the lack of staff awareness and the absence of a formal policy to address the placement of food for residents who require assistance or supervision during meals.
Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper glove use and hand hygiene during incontinent care for one resident. During an observation, a CNA performed perineal care for a resident who was always incontinent of urine and frequently incontinent of bowel, and who had severe cognitive impairment. The CNA's gloved hands came into contact with the resident's skin while cleaning the perineal area, but the CNA did not change gloves or wash hands before fastening a clean brief and assisting the resident with pants, despite facility policy requiring glove removal and hand hygiene after contamination. Interviews with the CNA, the Administrator, and the DON confirmed that gloves should have been changed and hands washed after contamination to prevent cross contamination. Review of the resident's care plan and the facility's infection control and perineal care policies further supported the requirement for proper glove use and hand hygiene. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control practices.
Failure to Report Abuse Investigation Results Timely
Penalty
Summary
The facility failed to report the results of an investigation into an alleged abuse incident involving a resident and a CNA to the appropriate state officials within the required five working days. The incident involved a resident who alleged that a CNA had pushed him back into his wheelchair during a disagreement about a smoke break. The resident, who has a history of schizophrenia, depression, and cognitive impairment, reported the incident to a nurse, who found no physical injuries upon assessment. The facility's administrator self-reported the incident to the Health and Human Services Commission (HHSC) but did not complete and submit the required Provider Investigation Report (Form 3613A) within the specified timeframe. The incident occurred when the resident became verbally aggressive with the CNA over a delay in being taken outside for a smoke break. The CNA reportedly told the resident he would take him out after finishing his charting, but the resident became upset and attempted to take himself outside. During the altercation, the resident claimed the CNA pushed him, although the CNA and another resident witness stated that the CNA only assisted the resident back into his scooter to prevent a fall. The facility's Licensed Vocational Nurse (LVN) assessed the resident and found no signs of injury, and the incident was reported to the facility's abuse coordinator and Director of Nursing (DON). Despite conducting an investigation and gathering statements from involved parties, the facility's administrator did not complete the necessary documentation to report the investigation's findings to the state within the required period. The administrator acknowledged the oversight, stating that the incident was deemed inconclusive, and the CNA involved did not return to the facility after the incident. The facility's policy requires that all allegations of abuse be thoroughly investigated and reported using the appropriate forms within five calendar days, which was not adhered to in this case.
Failure to Notify Resident's Representative and Physician of Changes in Condition
Penalty
Summary
The facility failed to notify the resident's representative and physician when there was a change in the resident's psychosocial status and when the resident ran out of the medication Risperidone. The resident, who had a history of Traumatic Brain Injury and Quadriplegic Cerebral Palsy, exhibited aggressive behavior and refused medication multiple times. Despite these significant changes, the facility did not inform the resident's family or physician in a timely manner, leading to a lapse in care and communication. The resident's care plan included administering psychotropic medications as ordered and obtaining consent from the resident or responsible party prior to medication use. However, the facility did not follow these interventions, as evidenced by the resident's refusal to take medication and the lack of documentation that the family was notified of the ongoing behaviors or the depletion of Risperidone. The facility's policy required notifying the resident's representative within 24 hours of a significant change, but this was not adhered to. Interviews with staff and the resident's family revealed that the facility had issues with medication management and communication. The family was only notified once about the resident's behaviors and medication depletion, despite multiple instances of aggression and refusal to take medication. The facility's failure to communicate effectively with the family and physician resulted in the resident not receiving the necessary medication and care, which could have been mitigated with proper notification and intervention.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of Resident #1. Specifically, the facility did not obtain and administer the antipsychotic medication Risperidone fifteen times between 4/23/24 and 5/1/24, as per the physician's orders. This failure was identified through interviews and record reviews, revealing that the resident did not receive the prescribed medication, which was critical for managing his traumatic brain injury and associated behaviors. Resident #1, a male with a history of traumatic brain injury and quadriplegic cerebral palsy, was admitted to the facility for respite care. The resident's care plan included the administration of Risperidone to manage potential adverse consequences from psychotropic medications. Despite this, the facility ran out of the medication and failed to notify the family in a timely manner. The facility's pharmacy did not provide the liquid form of Risperidone, and there was a lack of documentation and communication regarding the medication's unavailability and the steps taken to address it. Interviews with the facility's staff, including the Administrator and the Director of Nursing (DON), revealed inconsistencies and a lack of clarity regarding the procedures for obtaining medications for respite care residents. The staff believed that the family was responsible for providing the medication, while the family assumed the facility would manage it. This miscommunication led to Resident #1 missing multiple doses of Risperidone, resulting in increased aggression and behavioral issues. The facility's policy on unavailable medications was not effectively followed, contributing to the deficiency in care provided to Resident #1.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents in three of four halls reviewed for accidents and supervision. Specifically, the water temperatures in the shower rooms and resident sinks were found to be excessively high, posing a risk of burns to the residents. The temperatures recorded were significantly above the safe range, with readings as high as 141.3°F in Hall 400 and 136°F in Hall 500. These high temperatures were confirmed through observations and interviews with residents and staff, who reported that the water was too hot and could potentially cause burns. Resident #51, a male with severe cognitive impairment, reported that the showers on Hall 500 were too hot, and despite his complaints to the CNA, the water temperatures were not adjusted. Similarly, Resident #12, who had moderately impaired cognition and required limited staff assistance with bathing, also reported that the water in the Hall 500 shower was too hot and could burn someone if they were not careful. These reports were corroborated by temperature readings taken by the surveyors, which showed dangerously high water temperatures in multiple locations within the facility. Interviews with the Director of Nursing (DON) and other staff revealed a lack of awareness and proper monitoring of water temperatures. The DON acknowledged that the water could have burned residents, and a CNA admitted not knowing the correct water temperature range. The facility's maintenance staff used an inaccurate infrared thermometer, leading to incorrect temperature readings. The facility's policy required water temperatures to be between 100-110°F, but this was not adhered to, resulting in an Immediate Jeopardy situation being identified. The facility's failure to maintain safe water temperatures placed residents at risk of severe injury, serious harm, hospitalization, impairment, and/or death.
Failure to Honor Resident Smoking Preferences
Penalty
Summary
The facility failed to ensure that residents had the right to choose their schedule, specifically regarding the number of cigarettes they could smoke during their smoke breaks. This deficiency was identified for two residents, both of whom had a history of tobacco use and other medical conditions. Resident #12, a male with coronary artery disease and depression, was restricted to one cigarette per smoke break despite his previous habit of smoking two packs a day. Similarly, Resident #63, a male with major depressive disorder and anxiety, was also limited to one cigarette per break, even though he could safely manage his smoking materials independently. Interviews with staff revealed inconsistencies and a lack of awareness regarding the facility's smoking policy. The housekeeper and social worker both mentioned that residents were only allowed one cigarette per break, citing a supposed corporate policy. However, the facility's actual smoking policy did not contain any such restriction. The administrator admitted that the one-cigarette rule was a decision made by the department heads to manage residents' budgets and prevent theft, rather than a formal policy. The facility's documentation, including the Resident Smoking Council Meeting Minutes and the official smoking policy, showed no evidence supporting the one-cigarette rule. This discrepancy between the facility's practices and its documented policies led to the deficiency, as it restricted residents' rights to self-determination and choice, contrary to the facility's stated policies on resident rights and self-determination.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents. In Resident #4's room, the hot water faucet did not work, and the left closet door was missing, leaving the resident's clothing exposed. Resident #4, who had multiple diagnoses including chronic obstructive pulmonary disease, dementia, and diabetes, expressed that he had informed the staff about the non-functional hot water, but no action had been taken. In Resident #22's room, the sink only had cold water available. Resident #22, who had moderate cognitive impairment and required assistance with various daily activities, stated that she had not had hot water since moving into the facility. Additionally, the closet doors were missing, leaving the resident's clothing exposed. In Resident #32's room, the sink would not drain without the resident holding up the drain plug, and the hot water temperature was below 100°F. Resident #32, who had diagnoses including encephalopathy and dementia, mentioned that she did not mind the water not being hot but was unsure how long the drain had been malfunctioning. The facility's maintenance log showed no evidence that these issues were addressed, and the Director of Plant Operations admitted to delays and difficulties in obtaining parts to fix the problems.
Failure to Provide Appropriate Peri-Care and Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents who were incontinent of bladder. Specifically, the facility did not ensure proper hand hygiene and peri-care techniques were followed by CNAs. CNA B and CNA C did not wash their hands before, during, or after performing peri-care, and they did not follow the correct procedure of wiping from front to back. Instead, they used a zig-zag motion and did not change gloves between handling dirty and clean briefs, which could lead to cross-contamination and increased risk of infections for the residents involved. Resident #17, a female with severe cognitive impairment and frequent incontinence, was observed receiving improper peri-care from CNA C, who did not wash hands or change gloves during the procedure. Similarly, Resident #38, a female with dementia and complete incontinence, was observed receiving improper peri-care from CNA B, who also failed to follow proper hand hygiene and peri-care techniques. Both residents' care plans included specific interventions to prevent skin breakdown and urinary tract infections, but these were not adhered to during the observed care. Interviews with the CNAs revealed a lack of training and competency checks in peri-care procedures. CNA C admitted to not knowing the correct procedures and not having been trained or checked off on peri-care since employment. CNA B cited issues with access to handwashing facilities and also lacked skills competency checks. The Director of Nursing (DON) confirmed that no staff competencies had been performed since she started and was unaware of the required frequency for staff performance evaluations and training. The facility's policy on perineal care was not followed, contributing to the deficiencies observed.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for three residents. Resident #26, a female with severe cognitive impairment, had bed rails installed without any documented assessment for entrapment risks, attempts at less restrictive measures, or informed consent. Observations confirmed the presence of bilateral half side rails, and the resident was unable to be interviewed due to her condition. Resident #59, also with severe cognitive impairment, had bed rails installed without a physician's order, risk assessment, or informed consent. The care plan mentioned the use of side rails for bed mobility, but no documentation supported the necessary assessments or consents. Observations and interviews with staff revealed that the bed rails were present in the resident's room, and the responsible party refused to be interviewed. Resident #68, a female with multiple diagnoses including blindness and Down's syndrome, had bed rails installed with a physician's order but lacked documentation for risk assessment, attempts at less restrictive measures, or informed consent. Observations confirmed the presence of bilateral half side rails, and the resident was unable to be interviewed. Interviews with staff indicated a lack of awareness and adherence to the facility's policy on bed rail use, including the need for assessments and consents prior to installation.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to review the work of each Certified Nurse Aide (CNA) every 12 months for four CNAs (CNA-D, CNA-E, CNA-F, and CNA-G) out of five reviewed. The personnel files for these CNAs, who were hired between October and November 2021, showed no evidence of competency evaluations conducted at least every 12 months after their hire dates. This lack of evaluation could result in inadequate CNA performance while providing care for residents. During an interview, the Director of Nursing (DON) admitted that she had not performed any staff competencies since her hire in February 2024. She also stated that she was unaware of the requirement for annual competency evaluations and had not followed up to ensure that CNAs had the necessary training and documentation. The facility's policy, dated August 2017, mandates that competency evaluations be conducted initially and annually, and that a performance review of each nurse aide be conducted at least once every 12 months.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that residents with PRN orders for psychotropic drugs, specifically Lorazepam, were limited to 14 days. This deficiency was observed in six residents, all of whom had ongoing PRN orders for Lorazepam without a stop date. The residents involved had various diagnoses, including anxiety, depression, dementia, Alzheimer's, bipolar disorder, and other medical conditions. Despite the presence of these PRN orders, there was no documented rationale for the continued provision of Lorazepam in the physician progress notes from January 2024 to April 2024 for any of the residents involved. Resident #45, a female with severe cognitive impairment, had a PRN order for Lorazepam dated February 2022 with no stop date. Her MAR for April 2024 showed no evidence of Lorazepam being administered, and her physician progress notes lacked any documented rationale for the continued provision of the medication. Similarly, Resident #10, a female with bipolar disorder and anxiety, had a PRN order for Lorazepam dated February 2024 with no stop date. Her MAR indicated that Lorazepam was administered on two occasions in April 2024, but there was no documented rationale for its continued use in her physician progress notes. Other residents, including Resident #18, Resident #58, Resident #2, and Resident #52, also had PRN orders for Lorazepam without stop dates and no documented rationale for the continued provision of the medication. The Director of Nursing (DON) acknowledged awareness of the regulation on PRN psychotropic medications and admitted to missing the orders due to being very busy. The facility's policy emphasized the importance of regular review and appropriate use of psychotropic medications, but this was not adhered to in these cases.
Expired Food in Dry Storage
Penalty
Summary
The facility failed to ensure the dry food storage was not past their use-by dates, which placed residents at risk for foodborne illnesses. During an observation, it was found that the dry storage pantry contained six packages of sealed marshmallows, one opened box of shredded coconut, and one sealed box of black-eyed peas, all of which were past their use-by dates. The Dietary Manager (DM) acknowledged that there should have been no expired food in the pantry and admitted that the product dates should have been checked on a weekly basis as well as when new products arrived. Despite previous in-services for food safety, the DM admitted to not monitoring the stored food and incoming products closely enough, attributing the failure to the kitchen department head's oversight. The Administrator (ADMN) also confirmed that expiration dates on food products should have been checked daily and updated weekly, with food products being rotated accordingly. The ADMN stated that she would only go into the kitchen when necessary and relied on the DM to monitor the products. However, she acknowledged that ultimately, she was responsible for monitoring the DM. Both the DM and ADMN recognized that the failure in adhering to the chain of command and training protocols could have negatively impacted residents by potentially making them sick. The facility's food manager training and FDA Food Code guidelines were reviewed, emphasizing the importance of proper food labeling and rotation to prevent such deficiencies.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services. This failure was observed in 11 residents, where the facility did not maintain the required hospice forms and documentation, including the hospice plan of care and certificate of terminal illness. Additionally, the facility lacked physicians' orders for hospice care for several residents, which could place them at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. For Resident #45, the facility did not have a binder containing the required hospice forms and documentation, despite the resident being on hospice services for Alzheimer's Disease. Similarly, Resident #10, who had a terminal prognosis related to Huntington's Disease, did not have an order for hospice care or the necessary hospice documentation. Resident #18, with severe cognitive impairment and on hospice services for hemiplegia and hemiparesis following a cerebral infarction, also lacked the required hospice documentation. Other residents, including Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34, were found to be in similar situations where the facility did not maintain the necessary hospice documentation and physicians' orders. Interviews with the Director of Nursing (DON), Registered Nurse (RRN), and Social Services Director (SSD) revealed a lack of awareness and understanding of the requirement to maintain hospice documentation, which could lead to residents not receiving the care they needed due to a lack of continuity of care.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) received the required minimum 12 hours of annual in-service training. The CNAs in question, identified as CNA-D, CNA-E, CNA-F, and CNA-G, had no evidence of completing the mandatory training since their hire dates in October and November 2021. This lack of training was confirmed through a review of their personnel files, which showed no documentation of the required in-service hours. During an interview, the Director of Nursing (DON) admitted that she had not conducted any staff in-service competencies since her hiring in February 2024. She also revealed that she was unaware of the frequency and requirements for staff in-service training. The DON acknowledged that the failure to ensure proper training could negatively impact resident care, as untrained staff might not perform their duties correctly. The facility's policy mandates that nurse aide competencies be evaluated initially and annually, but this was not adhered to, leading to the identified deficiency.
Failure to Lock Medication Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed with one of the four medication carts reviewed. During an observation, an unlocked medication cart was found unattended by the nurses' station between the 200 and 400 halls, with a resident approximately six feet away. The cart contained various medications, including prescription drugs like Zoloft, trazodone, Singulair, Buspar, Baclofen, Keppra, lactulose, Sinemet, and Megace, as well as over-the-counter medications such as Aspirin, Tylenol, and Colace. RN A, who was responsible for the cart, admitted to leaving it unlocked due to being nervous and distracted during shift change. She acknowledged that she knew the cart should be locked when unattended and recognized the potential adverse reactions that could occur if a resident accessed the medications. The Director of Nursing (DON) confirmed that medication carts should always be locked when unattended and highlighted the potential negative impact, including allergic reactions or death, if residents accessed the medications. The DON noted that all nursing staff should monitor the medication carts to ensure they are locked. The facility's policy on the storage of medications, revised in August 2020, mandates that medications and biologicals be stored safely and securely, with access limited to authorized personnel. The policy also specifies that medication carts and supplies should be locked when not attended by authorized individuals.
Failure to Obtain Physician's Order and Consent for Secure Unit Placement
Penalty
Summary
The facility failed to ensure resident records were maintained with accepted professional standards and practices for completeness and accurate documentation for one resident. Specifically, the facility did not obtain a physician's order or consent from the resident or their representative before placing the resident in a secure unit. The resident, a [AGE] year-old female with severe cognitive impairment, was admitted to the facility with diagnoses including acute posthemorrhagic anemia, unspecified dementia, anxiety, and diabetes. Despite the resident's cognitive and behavioral issues, there was no documentation of a physician's order or consent for her placement in the secure unit. Interviews with the Director of Nursing (DON) and the Registered Nurse (RN) revealed that both were aware of the requirement for a physician's order and consent prior to placing a resident in a secure unit. However, they were unable to provide the necessary documentation and admitted that the consent form might have been lost. The facility's policy requires an assessment, consent, and a physician's order for placement in the Memory Care Unit, but these steps were not followed in this case. This failure could result in residents being placed in secure units without proper authorization or consent, potentially leading to involuntary seclusion.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccamey Convalescent Center | 21.2 mi | ★★★★★ | 9 | 0 |
| Sienna Nursing And Rehabilitation | 31 mi | ★★★★★ | 24 | 0 |
| Focused Care At Odessa | 31.7 mi | ★★★★★ | 12 | 0 |
| Avir At Monahans | 34.3 mi | ★★★★★ | 4 | 0 |
| Buena Vida Nursing & Rehab Odessa | 34.4 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.