Below 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 Crestpark Dewitt, Llc during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility did not have an RN on duty for at least 8 consecutive hours each day as required. Schedule review showed multiple days without RN coverage, and the Administrator, LPN, and DON all confirmed the recurring lack of RN presence, including on several weekends. The Facility Assessment identified RN nursing services as a needed resource for daily care and emergencies.
The facility failed to submit quarterly PBJ staffing data to CMS for one reporting period. The BOM stated she completed the monthly staffing data but missed the submission deadline, and the Administrator confirmed the data was not entered on time.
The facility failed to ensure proper food safety and hygiene practices. A dietary staff member cross-contaminated by handling raw meat and a cooking spray can without changing gloves or washing hands. Additionally, a dietary helper's hair was not fully contained while preparing and serving food, risking contamination. These actions were against the facility's sanitation policy requiring hairnets and frequent handwashing.
The facility's assessment was incomplete, missing critical information such as the governing body representative's name, a plan for recruiting and retaining medical personnel, and a list of necessary resources. The assessment also lacked evaluations of contracts, health IT resources, and the physical environment, as well as a risk assessment for emergency preparedness. The Administrator and Administrative Assistant acknowledged these omissions during an interview.
The facility failed to maintain Legionella surveillance as part of its water management plan, which is essential for reducing bacterial risk in the water system. The plan lacked a comprehensive diagram of water distribution and potential growth areas for Legionella. During an interview, the Maintenance Supervisor noted slow water heating in certain halls, indicating issues with temperature control measures.
A facility failed to ensure residents with trust accounts had access to personal funds after business hours and on weekends. A resident reported needing to obtain funds by Friday for weekend use. The BOM confirmed this process and was unsure if new residents were informed. The facility lacked a personal funds policy.
A surveyor found the whirlpool room door open with unsecured hazardous chemicals and razors accessible. Staff confirmed the room should be locked when not in use, and the DON provided a safety data sheet indicating potential harm from the chemicals. No policy on accidents and hazards was provided.
A facility failed to ensure a PRN psychotropic medication, Lorazepam, was not continued past 14 days without a physician's documented rationale and duration for a resident with anxiety. The resident's PRN order lacked a stop date, and necessary documentation was incomplete. The DON admitted to not following up on missing information and acknowledged the 14-day limit for PRN psychotropic medications. The facility lacked a written policy on gradual dose reductions, leaving the responsibility to the doctor.
A facility failed to maintain a medication error rate below 5%, resulting in errors for two residents. A resident with heart failure received Digoxin without a required heart rate check, and another resident with renal issues received Renvela without food and missed a dose of Tylenol. The errors were due to RN oversight and non-compliance with physician's orders.
A facility failed to properly reconcile and dispose of Lorazepam for a resident, as required by the manufacturer's instructions. The medication was found without a date indicating when it was opened, and discrepancies were noted in the narcotic log. The resident was severely cognitively impaired and receiving hospice care. The DON described the facility's process for narcotic disposal, but the lack of proper documentation suggests a failure in the system.
The facility failed to administer pneumococcal vaccines to two residents, as identified during a survey. A review of their immunization records showed no documentation of the vaccine, and the IPC confirmed they had not received it, providing their shot records as evidence.
A facility failed to coordinate with the state office for a PASARR evaluation for a resident with severe cognitive impairment and mental health diagnoses, resulting in the resident not receiving designated services. The DON admitted responsibility for ensuring PASARRs were completed but mistakenly believed it was unnecessary post-admission.
A resident with chronic obstructive pulmonary disease and coordination issues was found with overgrown toenails, indicating a failure in nail care provision. Despite having a care plan requiring assistance with personal hygiene, there was no documentation of nail care refusal. CNAs were responsible for non-diabetic nail care, but it was not documented, and the resident reported needing podiatrist visits for foot issues.
A resident with COPD was administered oxygen at a rate exceeding the physician's order of 2 to 4 liters per minute, with the concentrator set at 4.5 liters. The facility also lacked a comprehensive policy for respiratory care, as confirmed by the DON's statement.
A discrepancy in the accounting of Lorazepam was identified when the amount in the bottle did not match the narcotic log. The error was traced back to an incorrect entry in the log, and the facility lacked a formal process for narcotic counts, with multiple instances of single signatures instead of the required two. The DON acknowledged the issue, but the discrepancy persisted, indicating a lack of oversight.
A nurse failed to check a resident's heart rate before administering Digoxin, contrary to physician's orders which required withholding the medication if the pulse was below 60 BPM. The resident had moderate cognitive impairment, heart failure, and a heart assistive device. The nurse admitted to forgetting this step, and the DON confirmed the oversight could lead to serious outcomes.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility did not have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. A review of licensed nurse schedules from 09/29/2025 through 03/23/2026 showed no RN coverage for eight consecutive hours on 10/04/2025, 10/05/2025, 10/11/2025, 10/12/2025, 02/28/2026, 03/01/2026, 03/14/2026, and 03/15/2026. During interviews, the Administrator confirmed there were four days in the last four weekends without RN coverage for eight hours each day, LPN #1 stated the lack of RN coverage happened every other weekend, and the DON confirmed there was no RN present on the listed dates from October 2025 through March 2026. The Administrator also stated it was her responsibility to ensure the DON had an RN scheduled for at least eight hours each day. The Facility Assessment, last updated 02/20/2026, identified RN nursing services as a needed facility resource to provide competent support and care for the resident population every day and during emergencies.
Failure to Submit Quarterly PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for the October 2025 through December 2025 quarter. A review of the facility’s most recent PBJ report dated 03/12/2026 showed that no monthly staffing data had been submitted for that timeframe. During interview, the Business Office Manager stated she was responsible for entering the PBJ data, that the report contained staffing hours audited from payroll records, and that the missing submission was due to her forgetting the 02/15/2026 deadline even though the monthly data had been completed. The Administrator stated it was her responsibility to ensure the BOM completed a timely PBJ submission for each quarter and confirmed the data was not entered by the deadline.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards during food preparation and service. Observations revealed that a dietary staff member, while wearing gloves, handled raw meat and then touched a can of cooking spray without changing gloves or washing hands, leading to cross-contamination. Additionally, a dietary helper was observed with hair not fully contained within a bonnet while mixing ingredients and serving food, which could result in hair contaminating the food. Interviews with the dietary manager confirmed these lapses in hygiene practices, acknowledging the cross-contamination and the potential for hair to get into the food. The facility's policy on sanitation requires staff to wear a hairnet or cap and to keep hands clean by washing them frequently, which was not adhered to in these instances.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all necessary information to allocate resources and care for residents effectively. The assessment, dated 09/12/2024, was missing several critical components, including the name of the governing body representative involved in its completion, a plan for recruiting and retaining adequately trained medical personnel, and a comprehensive list of resources such as supplies and equipment necessary for resident care. Additionally, the assessment lacked an evaluation of contracts and agreements for goods and services, health information technology resources, and an evaluation of the physical environment to meet resident needs. There was also no reference to a facility-based and community-based risk assessment using an all-hazards approach for emergency preparedness. During an interview on 10/03/2024, the Administrator and Administrative Assistant (AA) were questioned about the facility assessment. The Administrator incorrectly identified herself as the governing body, while the AA named an owner of the facility. The AA admitted that portions of the assessment were missing because they did not answer the items appropriately. The AA also stated that the Quality Assurance and Assessment (QAA) committee was responsible for completing the facility assessment, and the Administrator claimed to have reviewed it to ensure all necessary components were in place. However, the deficiencies in the assessment had the potential to affect all 36 residents of the facility.
Deficiency in Legionella Surveillance and Water Management
Penalty
Summary
The facility failed to maintain Legionella surveillance as part of its water management plan, which is crucial for reducing the risk of bacteria in the water system. The water management plan, with an annual review date of 09/13/2024, identified Legionella as a bacteria that causes Legionnaires Disease, a severe type of pneumonia. The plan outlined that Legionella grows best in stagnant water or water with insufficient disinfectant, and at temperatures between 59 and 131 degrees Fahrenheit. However, the facility's water management plan lacked a comprehensive diagram showing where water is received, distributed, and where potential growth areas for Legionella exist, such as storage tanks and water heaters. Additionally, the plan did not identify situations that could encourage bacterial growth, such as biofilm presence, sediment, temperature fluctuations, and water stagnation. During an interview, the Maintenance Supervisor was asked to test the water temperature in a specific room, and it was observed that it took 8 minutes for the water to reach 107 degrees Fahrenheit. The Maintenance Supervisor noted that on certain halls, the water is slow to heat up, indicating potential issues with the water system's temperature control measures. The facility's water management plan required hot water to be stored above 160 degrees Fahrenheit and to flush the system for a minimum of 5 minutes, but these measures were not effectively implemented or monitored, contributing to the deficiency in Legionella surveillance.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents with a trust account had access to their personal funds after business hours and on weekends. This deficiency was identified for one resident, who reported that the facility managed their money and that funds needed to be obtained from the business office by Friday for weekend use. The Business Office Manager (BOM) confirmed that residents typically needed to visit the office by Friday to receive a check for funds or inform a nurse on the weekend, who would then contact the BOM to retrieve the funds. However, the BOM could not recall the last time this process was utilized on a weekend and was unsure if new residents were informed about this procedure. Additionally, the facility did not have a personal funds policy in place, as indicated by the Administrator.
Failure to Secure Hazardous Chemicals in Whirlpool Room
Penalty
Summary
The facility failed to ensure that potentially hazardous chemicals were secured and stored behind a locked door, leading to a deficiency. On September 30, 2024, a surveyor observed the door to the whirlpool room open, with various chemicals and items such as a 1-gallon jug of surface disinfectant cleaner, spray bottles of the same cleaner, a jug of tearless shampoo and body wash, and razors left unsecured. These items were accessible on an over bed table and directly on the whirlpool, posing a potential hazard to residents. Interviews with staff revealed that the door to the whirlpool room should have been closed and locked when not in use. A Certified Nursing Assistant (CNA) confirmed that the room contained chemicals that could be harmful to residents. The Director of Nursing (DON) provided a Material Safety Data Sheet for the surface disinfectant cleaner, which indicated that the chemical could cause moderate skin irritation and be harmful if swallowed. However, the facility did not provide a policy on accidents and hazards, nor did the typed statement from the DON address such a policy.
Failure to Document Rationale for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Lorazepam, was not continued past 14 days without a physician's documented rationale and duration for a resident diagnosed with anxiety. The resident's physician's orders indicated the use of Ativan 1 mg every 8 hours as needed for anxiety, but a consultation report revealed that the PRN order lacked a stop date. The report further indicated that the documentation did not include the indication for use, the anticipated duration of therapy, or the rationale for the extended time period, as these sections were left blank by the provider. During an interview, the Director of Nursing (DON) stated that she provided gradual dose reduction forms to doctors monthly and followed up to ensure completion. However, she admitted to not reaching out to providers if something was missing on the form. The DON acknowledged that she was aware of the 14-day limit for PRN psychotropic medications. Additionally, the facility did not have a written policy concerning gradual dose reductions, and the responsibility for filling out the form and providing a rationale for declination was left to the doctor.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in medication errors for two residents. For Resident #10, who had a diagnosis of heart failure and a heart assistive device, there was a physician's order for Digoxin 125 microgram with instructions to hold the medication if the pulse was less than 60 beats per minute. On the specified date, RN #2 administered Digoxin to Resident #10 without checking the heart rate, as required by the physician's order. RN #2 later acknowledged forgetting to check the resident's heart rate before administering the medication. For Resident #15, who was cognitively intact and had diagnoses of renal insufficiency, renal failure, and end-stage renal disease, there was a physician's order for Renvela 800 milligrams to be given with meals and Tylenol 650 mg twice a day. RN #2 administered Renvela to Resident #15 while the resident was not eating, contrary to the physician's order. Additionally, RN #2 forgot to administer the prescribed Tylenol. The Director of Nursing confirmed that Renvela should be given with food, and the facility's policy required medications to be administered in accordance with physician's orders and within a specified time frame.
Failure to Reconcile and Dispose of Lorazepam
Penalty
Summary
The facility failed to consistently implement a system to accurately reconcile and dispose of a controlled liquid narcotic, Lorazepam, according to the manufacturer's instructions. During an observation, a surveyor and an RN found a bottle of Lorazepam in a small refrigerator without a date indicating when it was opened, despite the manufacturer's guidelines requiring disposal 90 days after opening. The narcotic log showed discrepancies in the recorded amounts of Lorazepam, with no clear indication of when the bottle was opened or if it was disposed of in accordance with the guidelines. The resident involved was severely cognitively impaired and receiving hospice care, with a physician's order for Lorazepam to be administered as needed. The Director of Nursing explained the facility's process for removing and returning narcotics for destruction, which involved logging the medications, measuring liquid medications, and sending them for destruction via certified mail. However, the lack of a date on the Lorazepam bottle and the discrepancies in the narcotic log indicate a failure in the facility's system for managing controlled substances.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal vaccines to two residents, as identified during a survey. A review of the immunization records for these residents revealed that there was no documentation indicating they had received the pneumonia vaccine. The Infection Control Preventionist (IPC) confirmed during an interview that these residents had not been administered the pneumococcal vaccine, and provided their shot records as evidence. This deficiency was noted for two out of five residents reviewed for immunizations.
Failure to Complete PASARR Evaluation for Resident
Penalty
Summary
The facility failed to coordinate with the state-designated office to obtain a Preadmission Screening and Resident Review (PASARR) evaluation for a resident, identified as Resident #19. This oversight was discovered through interviews, record reviews, and facility document reviews. Resident #19 was admitted on February 28, 2023, with diagnoses including psychotic disorder with delusions, bipolar disorder, and anxiety disorder. The resident's quarterly Minimum Data Set (MDS) assessment on August 6, 2023, indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 7. The resident's care plan, revised on June 26, 2024, included monitoring for signs and symptoms related to their mental health conditions and the effectiveness of psychotropic medications. During an interview on October 3, 2024, the Director of Nursing (DON) admitted responsibility for ensuring PASARR evaluations were completed and sent to the State Designated Professional Associate. However, the DON acknowledged that a PASARR was not completed for Resident #19, as they mistakenly believed it was unnecessary after admission. This failure to conduct the required PASARR evaluation resulted in the resident not receiving designated services, as mandated by regulations.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #20, who was observed with toenails greater than a quarter inch in length and thick. The resident had a diagnosis of chronic obstructive pulmonary disease and a lack of coordination, requiring partial/moderate assistance with personal hygiene. Despite having a physician's order allowing for podiatrist visits as needed, there was no documentation indicating that nail care was refused by the resident. The resident's care plan indicated a self-care deficit in activities of daily living, necessitating staff assistance for personal hygiene. Interviews with staff revealed that nail care for non-diabetic residents was the responsibility of CNAs, who did not document nail care but could note it on bath sheets. The resident reported that a lady visited the facility but did not perform toenail care, and sometimes the resident needed to visit a podiatrist due to calluses and foot pain. The Director of Nursing provided a statement indicating that nail care was provided by CNAs on bath days and as needed, with diabetic nail care performed by licensed personnel only.
Oxygen Administration Deficiency for Resident with COPD
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician's ordered rate for a resident with chronic obstructive pulmonary disease (COPD). The physician's order specified that oxygen should be administered at a rate of 2 to 4 liters per minute via nasal cannula to maintain oxygen saturation above 93%. However, observations on multiple occasions revealed that the oxygen concentrator was set at 4.5 liters per minute, exceeding the prescribed rate. This discrepancy was confirmed by a registered nurse who acknowledged that the oxygen rate should be checked every shift to ensure compliance with the physician's orders. Additionally, the facility did not provide a comprehensive policy and procedure for respiratory care and services according to professional standards of practice. When requested, the Director of Nursing provided a typed statement indicating that the policy was to administer oxygen per physician's orders and to change tubing and storage bags weekly. This lack of a detailed policy may have contributed to the oversight in administering the correct oxygen rate for the resident.
Discrepancy in Lorazepam Accounting
Penalty
Summary
The facility failed to accurately account for a controlled liquid narcotic, Lorazepam, after it was administered to a resident with a diagnosis of anxiety. The discrepancy was identified when the surveyor and a registered nurse observed the medication storage and found that the amount of Lorazepam in the bottle did not match the narcotic log. The log indicated that 22.25 ml should have been remaining, but the bottle contained approximately 20 ml, resulting in a 2.25 ml discrepancy. The issue was compounded by an earlier error on 03/18/2024, where a dose was incorrectly added instead of subtracted from the log, leading to further confusion about the actual balance of the medication. The facility's Director of Nursing (DON) was informed of the discrepancy and acknowledged that the pharmacy consultant did not conduct narcotic audits, only verifying if the narcotic log matched the medications signed on the MAR as administered. The facility lacked a formal process for how nurses performed narcotic counts, although counts were conducted every shift. Additionally, there were 29 instances where only one signature was observed on the narcotic log instead of the required two signatures for a shift count. The DON provided a list of 14 licensed nurses who had counted the Lorazepam bottle after the initial discrepancy, but the issue persisted, indicating a lack of consistent oversight and accountability in the medication administration process.
Failure to Check Heart Rate Before Administering Digoxin
Penalty
Summary
The facility failed to ensure that a nurse checked the heart rate of a resident before administering Digoxin, a medication used to treat heart conditions by slowing down the heart rate and strengthening heartbeats. According to the physician's orders, the medication should be withheld if the resident's pulse is less than 60 beats per minute, and the pulse should be checked for one full minute. However, during an observation, a registered nurse did not check the heart rate of the resident before administering the medication. The resident involved had a moderate cognitive impairment, heart failure, and a heart assistive device. During an interview, the nurse admitted to forgetting to check the heart rate before administering the medication. The Director of Nursing confirmed that the nurse should have checked the heart rate as per the physician's orders, and failing to do so could potentially lead to a serious negative outcome for the resident. The facility's policy on administering medication also requires that vital signs be checked if necessary before administering medication.
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What surveyors actually found near you
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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 De Witt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dewitt Nursing Home | 0.8 mi | ★★★★★ | 3 | 0 |
| Crestpark Stuttgart, Llc | 18.7 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Star City Rehab & Nursing Center | 36.2 mi | ★★★★★ | 0 | 0 |
| Oak Grove Retirement Home | 38.2 mi | ★★★★★ | 5 | 0 |
| Maple Healthcare | 38.3 mi | ★★★★★ | 0 | 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.