Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestview Retirement Community during CMS and state inspections, most recent first.
A CNA refused to assist a resident with dementia and mobility limitations to the bathroom after the resident requested help, instead telling her to use her brief/diaper and speaking over her in a rude tone while turning off the call light. Video footage captured the interaction, and the facility determined the CNA’s actions constituted neglect and could be perceived as verbal abuse.
Unlocked Medication Cart Left Unattended: Medication Cart #1 was observed unlocked and unattended on a hall while no nursing staff were nearby. Med Aide B stated she was responsible for locking the cart when working from it, but did not explain why it was left unlocked. The DON and Administrator stated the cart was expected to be locked whenever the Nurse or Med Aide was not standing in front of it, and the facility policy required medication carts to be secured during med pass and locked when out of the nurse's view.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
Staff, including management, entered the kitchen without required hair restraints and prepared food without wearing gloves, in violation of facility policies. Interviews revealed that while staff were aware of the requirements, lapses occurred due to oversight and lack of comprehensive training for all personnel involved in food service.
A facility reported a medication error rate of 36.36%, involving two residents. One resident received Metoprolol despite a low heart rate, against physician orders. Another resident's medications were crushed and mixed with pudding, resulting in only half being ingested. Staff interviews revealed inconsistencies in following medication administration protocols.
A resident in an LTC facility experienced a significant medication error when a medication aide crushed her extended-release (ER) medications, including Glipizide, Bupropion, and Metoprolol Succinate, and mixed them with pudding. The resident, who has a history of type 2 diabetes, atrial fibrillation, and dementia, received only half of her medications as she spit out the second bite. Staff interviews confirmed that ER tablets should not have been crushed, and the Medical Director assessed the resident with no adverse effects noted.
The facility failed to properly store, label, and discard food products in its kitchen, leading to potential health risks. Observations revealed expired and unlabeled food items in the walk-in freezer and an inadequately cleaned industrial can opener. Interviews with staff confirmed lapses in daily checks and adherence to food safety standards, as outlined in the facility's manual and FDA guidelines.
Resident Denied Bathroom Assistance and Spoken to Rudely
Penalty
Summary
The facility failed to ensure a resident was free from abuse and neglect when a CNA responded to the resident’s request to use the bathroom with rude, dismissive statements and refused to assist her to the toilet. The resident was an older female with diagnoses including unspecified dementia, difficulty walking, need for personal care assistance, and osteoporosis. Her assessments showed she used a wheelchair or walker and required assistance with toileting, toilet transfer, personal hygiene, dressing, and other ADLs. Her care plan also directed staff to anticipate and meet her needs, keep her call light within reach, and provide prompt response to requests for assistance. Video footage from the resident’s room showed the CNA entering to answer the call light while the resident was in bed and asking for help to the bathroom. The CNA responded in a rude tone, told the resident she was not taking her to the bathroom, instructed her to use her brief/diaper instead, and said she was too weak to get up. The CNA turned off the call light, spoke over the resident while she was trying to explain her need, and walked away while continuing to tell her to use the bathroom in her brief and to let her know when she was finished. A second video showed similar conduct, including the CNA stating she was irritated, refusing to take the resident to the bathroom, and turning off the call light while gathering supplies. The facility’s investigation determined the CNA did not follow proper procedures and had neglected the resident by refusing to assist her to the bathroom when requested. The Administrator and DON later stated the CNA’s tone and statements could be perceived as verbal abuse and that the resident was expected to be assisted to the bathroom at any time during the day or night. The report also noted the resident’s psychosocial harm assessment found she was at baseline and not experiencing anxiety, depression, behaviors, or distress at the time reviewed.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication Cart #1 was observed unlocked on the left side at the end of 100 hall during a survey observation, and no nursing staff were seen near the cart at that time. Med Aide B later exited a resident room and walked to the cart, and during interview stated she had been trained on medication storage but was responsible for locking the cart when working from it. She also stated that if the cart was left unlocked and unattended, a resident could get into it and take medication that did not belong to them, and she did not respond when asked why she left the cart unlocked. The DON stated all medication carts were expected to be locked when the Med Aide or Nurse was not standing in front of them, and that the assigned Nurse or Medication Aide was responsible for ensuring the cart was locked. The Administrator also stated the cart was to always be locked and that the assigned Nurse or Medication Aide was responsible for securing it. Record review of the facility policy on Security of Medication Cart stated the medication cart shall be secured during medication pass, the nurse must secure the cart to prevent unauthorized entry, and medication carts must be securely locked at all times when out of the nurse's view.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Follow Food Safety Protocols in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as evidenced by multiple staff not following required protocols. On one occasion, the Executive Director (ED) and the Director of Resident Management (DRM) entered the kitchen without wearing hair restraints, despite facility policy mandating their use regardless of hair length. The DRM acknowledged forgetting to wear a hairnet due to being in a hurry and recognized the risk of hair contaminating food. The ED also did not wear a hairnet while in the kitchen. Additionally, the Dining Manager (DM) was observed preparing ham sandwiches without wearing gloves, handling bread, lettuce, and deli ham with bare hands before realizing the oversight and donning gloves. The DM admitted to knowing the requirement for glove use but failed to comply due to being distracted by multiple tasks. Interviews with staff confirmed that all personnel entering the kitchen are expected to wear hairnets and that gloves are required when handling ready-to-eat foods, as outlined in facility policies. The Lead Dietitian (LD) stated that audits are performed to ensure compliance, but training had not been provided to the ED, DRM, or DM. The DM, responsible for kitchen operations, indicated he had not trained the ED due to reporting structure and had only trained the DRM on hairnet use. The facility's policies on uniform dress and glove use were reviewed and found to require hair restraints and gloves during food preparation, but these were not consistently followed by staff.
High Medication Error Rate and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported error rate of 36.36% based on 16 errors out of 44 opportunities. This involved two residents during medication administration. One resident, a male with a history of dysphagia, thrombocytopenia, bradycardia, hypertension, and edema, was administered Metoprolol despite a heart rate of 54, contrary to the physician's order to hold the medication if the heart rate was below 60. The LVN responsible for administering the medication acknowledged the error and the potential for adverse effects. Another resident, a female with type 2 diabetes, atrial fibrillation, a history of stroke, and dementia, was given her medications crushed and mixed with pudding. The resident was unable to swallow all the medications and spit out approximately half of them. The MA administering the medications documented the partial administration and informed the LVN. The resident confirmed she usually takes her medications crushed but had difficulty swallowing them on this occasion. Interviews with staff, including the DON and the Administrator, revealed inconsistencies in medication administration practices, such as crushing medications and not following physician orders. The facility's policy on medication errors defines such errors as deviations from physician orders or accepted standards. Despite training records indicating that the MA had been trained on proper medication administration techniques, the errors persisted.
Crushing of ER Medications Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of extended-release (ER) medications. A medication aide (MA B) crushed the resident's ER medications, including Glipizide, Bupropion, and Metoprolol Succinate, and mixed them with pudding for administration. This action resulted in the resident receiving only half of the medications, as she spit out the second bite. The incident was documented, and the licensed vocational nurse (LVN A) was notified. The resident involved was an elderly female with a history of type 2 diabetes, atrial fibrillation, cerebral infarction, speech and language deficits, and dementia. Her comprehensive care plan noted issues with medication refusal and required anti-hypertensive and cardiac medications to be administered as ordered. The resident was observed to have difficulty swallowing the medications, leading to her spitting them out. Interviews with staff revealed that the MA routinely crushed the resident's medications, including ER tablets, which should not have been crushed. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the ER tablets should not have been crushed, as this could lead to a large dose being released at once. The Medical Director was notified of the error and assessed the resident, finding no adverse effects. The facility's policy on medication errors and training records indicated that staff were trained on proper medication administration techniques, including the handling of ER medications.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and sanitation practices in its kitchen, as observed during a survey. Specifically, the facility did not discard food products in the walk-in freezer that were past their indicated use-by dates, nor did they label and date food products appropriately. This included items such as breaded cod, salmon, pork, and chicken wings, some of which had visible ice crystals, indicating potential freezer burn. Additionally, the industrial can opener in the kitchen was found to have a sticky substance on and around the cutting blade, suggesting inadequate cleaning practices. Interviews with the Dietary Manager, Chef, and other kitchen staff revealed that there was an expectation for daily checks of refrigerators and freezers to ensure expired food products were discarded. However, these checks were not effectively carried out, as evidenced by the presence of outdated and unlabeled food items. The Dietary Manager acknowledged that the observed items should have been discarded and emphasized the importance of labeling to prevent contamination and ensure food safety. The Chef and other staff members also recognized their responsibility in labeling and discarding expired food products to prevent potential health risks to residents. The facility's Food Safety and Quality Assurance Standards Manual and the FDA Food Code were reviewed, highlighting the requirement for proper labeling, dating, and rotation of food stock to prevent the use of expired items. Despite these guidelines, the facility's practices did not align with the standards, leading to the identified deficiencies. The Administrator confirmed the expectation for proper labeling and disposal of expired food products, acknowledging the potential for resident illness if these practices were not followed.
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Illustrative
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Bryan | 0.1 mi | ★★★★★ | 19 | 0 |
| Lampstand Nursing And Rehabilitation | 0.4 mi | ★★★★★ | 22 | 0 |
| Legacy Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 16 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 5.5 mi | ★★★★★ | 16 | 1 |
| Fortress Nursing And Rehabilitation | 6.3 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.