Crowell Memorial Home
Crowell Memorial Home in Blair, NE — inspection on September 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the MDS Manual, a score of 8 to 12 indicates moderately impaired cognition.-Required partial to moderate assistance with eating, oral hygiene, upper body dressing, personal hygiene, sitting to standing position, and toilet transfers. -Used chair and bed alarms daily.
Record review of Resident 4's Comprehensive Care Plan (CCP) dated 7/10-2024 revealed Resident 4 was at risk for falls.
The goal identified on Resident 4's CCP was Resident 4 would be free of falls through the next review date.
Interventions listed were to assess for pain, encourage Resident 4 to reside in the lounge area, attend activities and encourage socialization, Keep snacks at bed time and to use a pd (movement of pressure detection) alarm in Resident 4's wheelchair or bed due to Resident 4's non-compliance with calling for assistance.
Record review of a Incident & Investigation sheet dated 9/10-2025 revealed Resident 4 was found on the floor.
Further review of the Incident & Investigation sheet dated 9/10-2025 revealed the call light within reach was identified as the intervention in place at the time of Resident 4 being found on the floor.
The wheelchair, bed/chair alarm was not identified as being in use at the time of Resident 4 being found on the floor.
According to the Incident & investigation sheet dated 9-10-2025 the post fall follow up intervention was the use of the sit stand alarm to the bed would be implemented. On 9-25-2025 at 12:34 PM an interview was conducted with Registered Nurse (RN) A.
During the interview RN A reported Resident 4 did have falls and that a alarm pad was in use for the resident. RN A reported when Resident 4 was found on the floor on 9-10-2025 an alarm should have been in place. On 9-25-2025 at 2:45 PM an interview was conducted with the Director of Nursing.
During the interview the DON reported Resident 4 did have falls and the pd alarm should have been in place according to resident 4's care plan.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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