Above 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestview Healthcare Residence during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Staff failed to consistently monitor and document refrigerator and freezer temperatures, clean and sanitize food storage areas, and ensure proper labeling and separation of resident and staff food items. Incomplete logs, unclean equipment, and unclear staff responsibilities led to improper food storage and sanitation practices throughout the kitchen and nourishment rooms.
Staff failed to perform required hand hygiene during care for two residents—one during perineal and catheter care by a CNA, and another during wound care by an LVN—resulting in lapses where hands were not sanitized between glove changes, despite facility policy and staff awareness of proper infection control procedures.
The facility did not ensure that controlled medications were accurately reconciled and documented at the start and end of each shift for two medication carts. Multiple instances of missing signatures and incomplete narcotic count sheets were identified, despite staff and policy requirements for both off-going and on-coming staff to count and sign for narcotics at each shift change.
A resident with cognitive impairment was left unattended in a shower room for about 30 minutes by an RN and a CNA, despite requiring substantial assistance with showering. The incident was reported by an outside representative, and the resident did not recall the event or suffer any physical injury. Interviews confirmed that leaving residents unattended in the shower room is against facility policy.
A resident with Multiple Sclerosis and mobility issues was injured during a transfer due to inadequate supervision and assistance devices. The resident was transferred using a standing pivot transfer by one staff member instead of a mechanical lift, resulting in a twisted knee. The incident was caused by a communication failure regarding the resident's transfer status, leading to outdated information being used by the CNA.
The facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating their needs. A resident with complex medical conditions and intact cognition had his call light out of reach, requiring assistance from his roommate. Another resident with a history of falls had her call light inaccessible, while a third resident, independent in daily activities, also reported an unreachable call light. A fourth resident, dependent on staff for transfers, had her call light string hanging out of reach. Staff interviews confirmed the expectation for accessible call lights, yet this was not consistently practiced.
The facility failed to maintain a safe, clean, and homelike environment for three residents, leading to cluttered and unsanitary conditions. A resident's room was messy with a disheveled bed and full trash can, while another's room had cluttered counters and personal items on the floor. A third resident's room was obstructed by boxes and furniture, with dirty containers and marked curtains. Staff interviews revealed challenges in maintaining cleanliness due to clutter, and the facility lacked a policy on personal items.
The facility failed to secure medication storage and ensure proper labeling and temperature control. A medication cart was found unlocked and unattended, and a vial of Influenza Vaccine in the medication room refrigerator was not labeled with the date it was opened. The refrigerator's temperature log was incomplete, indicating a lack of daily monitoring. The DON confirmed that these practices did not meet the facility's expectations.
The facility failed to maintain professional standards for food service safety, with personal items found in the kitchen prep area and food in refrigerators and freezers not properly covered, labeled, or dated. Staff interviews confirmed that personal items should be stored in designated areas, and all food items should be labeled and dated according to policy.
The facility failed to maintain an effective infection control program during a lunch meal service, where staff members, including the DON, ADON, LVN, and CNAs, were observed touching the rims of residents' cups with bare hands. This improper handling, despite hand hygiene practices, posed a risk of cross-contamination. Interviews revealed a lack of awareness and understanding among staff about the potential harm and proper procedures for handling cups.
The facility failed to inform two residents of their financial responsibilities by not providing a SNF ABN when discharged from skilled services before covered days were exhausted. The absence of a policy and staff uncertainty contributed to this deficiency.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Deficient Food Storage, Sanitation, and Temperature Monitoring in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and all nourishment rooms reviewed. Observations revealed that staff did not consistently conduct or document required temperature checks for refrigerators and freezers in the kitchen and nourishment rooms. Temperature logs were incomplete or missing entries for multiple days and shifts, and some units lacked thermometers altogether. Additionally, the 3-compartment sink log for the kitchen showed missing documentation of water temperature and sanitation solution concentration checks after dinner service on specific dates. Further inspection of the nourishment rooms revealed that refrigerators and freezers were not cleaned or sanitized as required. There was visible evidence of spills, residue, and buildup of ice and frost, with some units not maintaining safe temperatures as indicated by thermometer readings and physical inspection. Food and beverage items stored in these units were not labeled or dated, and personal staff items were found commingled with resident food, despite posted directives prohibiting this practice. Items such as opened bottles, ice cream, and leftovers were observed without proper identification, and some units contained non-resident items like ice packs and personal snacks. Interviews with staff and administration indicated confusion and lack of clarity regarding responsibility for cleaning, temperature monitoring, and maintenance of nourishment room refrigerators and freezers. While some staff believed nursing was responsible, others were unsure or thought housekeeping or kitchen staff might be involved. The facility lacked a specific policy assigning these duties, and the existing policy on refrigerator temperature monitoring was not consistently followed. This lack of clear assignment and adherence to procedures contributed to the observed deficiencies in food safety and sanitation.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during personal and wound care procedures. For one resident with a neurogenic bladder and an indwelling Foley catheter, a CNA did not perform hand hygiene on two occasions when changing from dirty to clean gloves during perineal and catheter care, despite the presence of Enhanced Barrier Precautions and available PPE. The CNA acknowledged that hand sanitization was required with each glove change but admitted to missing steps due to nervousness. The resident was cognitively intact and required regular catheter care as per care plan and physician orders. In a separate incident, an LVN providing wound care to another resident with a skin tear on the leg failed to sanitize hands between glove changes after removing a soiled dressing and before cleansing the wound. The LVN also attributed the lapse to nervousness, though she was aware of the hand hygiene expectations. Both the DON and Infection Control Practitioner confirmed that facility policy required hand hygiene before donning gloves, between glove changes, and after completing procedures, and that staff were trained on these protocols during orientation and ongoing education. Observations and interviews confirmed that these lapses in hand hygiene occurred during direct care.
Failure to Accurately Reconcile and Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were in order and that all controlled medications were accurately reconciled at the start and end of each shift for two medication carts. Record reviews revealed multiple instances of missing documentation on the Change of Shift Narcotic Count Sheets for both carts, with specific dates and shifts lacking required signatures and counts. This failure was confirmed through interviews with staff, including a Certified Medication Aide (CMA), a Licensed Vocational Nurse (LVN), and the Assistant Director of Nursing (ADON), all of whom acknowledged the expectation that both off-going and on-coming staff count and sign for narcotics at each shift change. The facility's policy requires nursing staff to count controlled drugs at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count and documenting any discrepancies. Despite this policy, the audit process conducted by the ADON identified deficiencies in narcotic count documentation, and staff interviews confirmed the established procedures were not consistently followed. The administrator also acknowledged the expectation for shift-to-shift narcotic counts and the potential for negative outcomes if the process is not adhered to.
Resident Left Unattended in Shower Room
Penalty
Summary
The facility failed to protect a resident from neglect when a registered nurse (RN) and a certified nursing assistant (CNA) left a resident unattended in the shower room for approximately 30 minutes. The resident, who has a significant level of cognitive impairment and requires substantial assistance with showering, was left in soiled undergarments. This incident occurred after the RN placed the resident in the shower room at the request of the CNA, who intended to attend to the resident after completing her rounds. The resident, a female with diagnoses including generalized atherosclerosis, unspecified dementia, and abnormalities of gait and mobility, was admitted to the facility with a care plan that required staff assistance for various activities of daily living, including bathing. The incident was reported by an outside representative who noticed the resident was left alone in the shower room and later informed the social worker. The resident did not recall the event and did not show any signs of physical injury or negative outcomes from the incident. Interviews with facility staff, including the Director of Nursing (DON), confirmed that it is against the facility's policy to leave residents unattended in the shower room. The RN involved acknowledged that he should have provided the hygiene care himself and communicated better with the CNA. The facility's abuse prohibition policy emphasizes the residents' right to be free from neglect, which was not upheld in this instance.
Failure to Ensure Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, leading to an incident where the resident was transferred using a standing pivot transfer by one staff member instead of a mechanical lift. During the transfer, the resident's leg did not pivot well, resulting in a twisted knee that later caused swelling and pain. The resident had a history of Multiple Sclerosis, muscle weakness, and abnormalities of gait and mobility, requiring extensive assistance with two persons for transfers as per the Quarterly MDS assessment. However, the care plan did not specifically address the resident's transfer needs at the time of the incident. The incident occurred due to a communication failure regarding the resident's transfer status. The Director of Therapy verbally communicated a change in transfer status to another CNA but failed to inform clinical leadership, resulting in the absence of an official order for a two-person mechanical lift transfer. Consequently, the CNA performed the transfer based on outdated information, leading to the resident's injury. The facility's policy on safe lifting and movement of residents was not adhered to, contributing to the deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #23, a 74-year-old male with intact cognition and multiple complex medical conditions, was observed to have his call light out of reach, requiring him to ask his roommate for assistance. His care plan specifically included the intervention to keep the call light within reach, which was not adhered to during the surveyor's observation. Similarly, Resident #57, a female with intact cognition and a history of falls due to noncompliance with using a walker, was found with her call light between the wall and the bed, near the floor, making it inaccessible. Her care plan emphasized the importance of keeping the call light reachable to prevent falls, yet this was not implemented. Resident #83, a male with intact cognition and independent in activities of daily living, also reported that his call light was not within reach, and he had to rely on his roommate to call for assistance. Resident #45, a female with intact cognition and dependent on staff for personal hygiene and transfers, was observed sitting in a bariatric wheelchair with her call light string hanging several inches above the bed, out of her reach. Despite her care plan's directive to ensure the call light was accessible, she had to wait for staff or ask her roommate for help. Interviews with staff, including an LVN, CNA, DON, and ADM, confirmed the expectation that call lights should be within reach, yet this was not consistently practiced, leading to the deficiency.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, leading to a deficiency in maintaining a well-kept environment. Resident #57, a female with intact cognition and multiple health conditions, was observed in a cluttered and messy room with a disheveled bed and a full trash can. The resident reported that housekeeping did not sweep and mop as expected. Resident #23, a male with intact cognition and dependent on staff for personal hygiene, was found in a room cluttered with items stacked on counters and personal items on the floor. The bathroom contained a walker on the shower floor with soiled underwear and socks. Resident #66, a female with intact cognition and several health diagnoses, had a room cluttered with boxes and furniture obstructing the sink, along with dirty food containers and marked privacy curtains. Interviews with staff revealed that housekeeping was expected to clean daily, but clutter in resident rooms posed challenges for maintaining cleanliness. The housekeeping supervisor acknowledged the difficulty in sweeping and mopping around clutter, while the DON expressed concerns about clutter being a fire hazard and cleanliness issue. The administrator admitted awareness of the ongoing clutter problem, which led to issues with bugs, mildew, mold, tripping hazards, and fire risks. Despite these acknowledgments, the facility lacked a policy regarding personal items for residents, contributing to the deficiency in providing a safe and clean environment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, under proper temperature control, and labeled according to professional principles. During an observation, a medication cart was found unlocked and unattended at the nurse's station, containing insulin pens, needles, and various medications. LVN A, who was present at the nurse's station, was unaware of the cart being unlocked and did not see an issue with the surveyor inspecting it. The Director of Nursing (DON) stated that medication carts should be locked when not attended to prevent unauthorized access by residents or visitors. Additionally, a multi-dose vial of Influenza Vaccine was found in the medication room refrigerator without a label indicating the date it was opened. The refrigerator's temperature log showed several days in April without recorded entries, indicating a lack of daily monitoring. The DON confirmed that opened vials should be dated and that the refrigerator temperature should be checked daily to ensure medication effectiveness. The facility's policies require that all compartments containing drugs be locked when not in use and that medications requiring refrigeration be stored properly.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's food storage and sanitation practices. Personal items, such as a pink travel cup, car keys, and a cell phone charger, were found on kitchen prep tables, which should have been free of such items. Additionally, a Styrofoam drink container with a red liquid was found in Refrigerator #1, which was not appropriate for the kitchen area. Interviews with dietary aides and the dietary manager confirmed that personal items should be stored in the dietary manager's office, and personal drinks should be kept in the staff refrigerator. Further observations revealed that food and beverages in the kitchen's refrigerators and freezer were not properly covered, labeled, or dated. Items such as sliced cheese, whipped topping, milk, peeled and cooked eggs, and frozen corn were found without appropriate labeling or dating. The facility's policy on food receiving and storage, as well as the Federal Drug Administration Food Code, requires that all refrigerated and frozen foods be covered, labeled, and dated. Interviews with dietary aides and the dietary manager indicated that labeling and dating were the responsibility of all kitchen staff, with the dietary manager ensuring compliance through regular rounds.
Inadequate Infection Control During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Director of Nursing (DON), Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN) C, and Certified Nursing Assistants (CNA) D and E during a lunch meal service. These staff members were observed touching the rims of residents' cups with bare hands, despite the cups being covered with ill-fitting plastic lids. This occurred during the meal service for 29 residents, and although hand hygiene was performed between residents, the improper handling of the cups posed a risk of cross-contamination. Interviews with the involved staff revealed a lack of awareness and understanding of the potential harm caused by their actions. CNA D and CNA E were unaware of the proper procedure for handling cups, and the ADON admitted that the rush to serve meals contributed to the oversight. LVN C acknowledged the difficulty in handling the cups correctly due to their arrangement on the tray. The DON was unaware of the inadequate coverage provided by the lids and emphasized the importance of handling cups by the sides to prevent contamination. The facility's infection prevention and control program policy and hand hygiene policy were reviewed, highlighting the expectation for staff to follow proper procedures to prevent the spread of infection.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to inform residents of the services available and the charges for those services, including any charges not covered under Medicare/Medicaid or by the facility's per diem rate. This deficiency was identified for two residents who were not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services before their covered days were exhausted. The absence of the SNF ABN form in the residents' electronic medical records indicates that the facility did not notify them of their financial responsibilities for services not covered by Medicare. Resident #300, a female with moderately impaired cognition, and Resident #301, a female with intact cognition, were both affected by this deficiency. The facility's administrator admitted that there was no policy regarding ABN notifications and that staff were unsure of the process or who was responsible for providing the form to residents. This lack of policy and clarity among staff led to the failure to provide the necessary notifications to the residents, potentially placing them at risk of being unaware of changes to their financial responsibilities.
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 75 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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 Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeshore Village Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 6 | 0 |
| The Atrium Of Bellmead | 2.5 mi | ★★★★★ | 2 | 0 |
| Ivy Creek Wellness & Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
| St. Catherine Center | 2.9 mi | ★★★★★ | 6 | 0 |
| Woodland Springs Nursing Center | 3 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.