Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 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.
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.
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 August 2026) and official state health department websites.