Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Crestwood Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with bipolar disorder had a PASRR Level I screening that incorrectly marked mental illness as no, even though the admission MDS listed bipolar disorder as an active diagnosis. The MDS Coordinator confirmed the screening was inaccurate, and the DON and Administrator acknowledged the resident could miss specialized services if the PASRR Level I was not correctly marked.
A resident with ESRD on hemodialysis had a physician order for CBC and CMP every Monday for 4 weeks, but only one set of labs was found and the remaining weekly labs were not completed. RN, ADON, and DON interviews confirmed the missing labs, and the DON stated the PA had not realized the resident was a dialysis patient when the order was entered.
A resident with dementia, Parkinson's disease, and total incontinence was observed during incontinent care when a CNA cleaned the peri area and then touched the resident's gown, arm, and upper thigh with dirty gloves before changing gloves and washing hands. The CNA said she forgot to change gloves, and the CNA, another CNA, LVN, ADON, and DON all acknowledged gloves should be changed and hands sanitized after a dirty procedure; the Regional Nurse also noted there was no incontinent care proficiency for the CNA, and the facility's perineal care policy did not address glove changes or hand hygiene during the task.
The facility did not orally inform residents of their rights, as required, affecting several residents. The new AD, unaware of this responsibility, had not reviewed resident rights during council meetings since her certification. Meeting minutes from June to October 2024 confirmed this oversight. The Operations Manager noted that while residents received written rights upon admission, the AD should discuss them in meetings.
The facility did not report a roof collapse incident on a secured locked unit to the state agency within the required 24-hour timeframe. The incident, caused by a storm and insufficient roof covering, led to water pouring into the building. Staff promptly relocated residents, and no injuries were reported. The Director of Operations reported the incident late, misunderstanding the reporting requirements.
PASRR Level I Screening Incorrectly Marked No for Mental Illness
Penalty
Summary
The facility failed to ensure the PASRR Level I screening accurately reflected Resident #85’s status. Resident #85 was admitted with diagnoses including bipolar disorder, chronic kidney disease stage 4, and frontotemporal neurocognitive disorder. Her admission MDS, dated 09/15/2025, showed section I (Active Diagnoses) marked for bipolar disorder, but the PASRR Level I screening for the same admission date marked mental illness as no, indicating there was no evidence or indicator of mental illness. The MDS also showed a BIMS score of 12 and section A1500 marked no for serious mental illness and/or intellectual disability or a related condition. During interview, the MDS Coordinator stated she was responsible for the MDS and PASRRs at the time of admission and, after reviewing the PASRR software and admission MDS, agreed the Level I screening was marked no for mental illness even though bipolar disorder was listed as an active diagnosis. She stated bipolar disorder would be a possible qualifying diagnosis for PASRR specialized services and that the resident could possibly qualify for specialized services and miss receiving them. The DON and Administrator also stated the resident could possibly miss out on specialized services if the PASRR Level I was incorrectly marked no for mental illness. The facility policy stated all residents must receive a PASRR Level I screening and that a positive Level I screening requires a PASRR Level II evaluation.
Ordered CBC and CMP Not Obtained for Dialysis Resident
Penalty
Summary
The facility failed to obtain ordered laboratory services for one resident who was receiving hemodialysis and had diagnoses including dependence on renal dialysis, end stage renal disease, encephalopathy, and type 2 diabetes. The physician ordered a CBC and CMP every Monday for 4 weeks beginning 12/4/25, but the record showed only labs from 12/5/25 were available. No labs were found for the following Mondays: 12/8/25, 12/15/25, 12/22/25, or 12/29/25. The resident’s admission MDS indicated a BIMS score of 15, showing he was cognitively intact, and the care plan documented hemodialysis on Monday, Wednesday, and Friday for renal failure with fluid overload or potential fluid volume overload related to kidney failure. The care plan did not address labs or lab orders. During interview, the resident stated staff were nice and that he went to dialysis three times per week. Staff interviews confirmed the ordered labs were not completed. RN A stated the facility did not have all of the resident’s labs and confirmed no labs were drawn on the four Mondays listed. The ADON also stated the other labs were not done. The DON stated the PA did not realize the resident was a dialysis patient when the weekly lab order was entered, and later said the PA discontinued the order after she called him. The DON and ADON both stated the order had not been changed or discontinued before that day, and the DON acknowledged the order should have been caught earlier.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control practices. Resident #60 was a female with diagnoses including dementia, Parkinson's disease, and senile degeneration of the brain. Her MDS indicated she had no speech, was rarely or never understood and rarely or never understood others, had short-term and long-term memory problems, and was dependent on staff for toileting hygiene. She was always incontinent of urine and bowel, and her care plan indicated she required assistance with activities of daily living and staff would change her brief and provide assistance as needed. During an observation of incontinent care, CNA C cleaned Resident #60's front peri area and then, without changing her gloves or sanitizing her hands, touched the resident's gown, arm, and upper thigh with the same dirty gloves before changing gloves and washing hands. In interviews, CNA C said she was nervous, forgot to change her gloves, and acknowledged she should have changed her gloves and cleaned her hands before touching the resident. CNA D, LVN E, the ADON, and the DON all stated staff should change gloves and sanitize hands after a dirty procedure and that touching the resident with dirty gloves could cause cross contamination and infection. The Regional Nurse stated there was no incontinent care proficiency for CNA C, and the facility's Perineal Care Policy did not address glove changes or sanitizing hands during incontinent care, while the Hand Hygiene Policy required hand hygiene before moving from a contaminated body site to a clean body site and after removing gloves.
Failure to Orally Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were orally informed of their rights, affecting six residents who were interviewed during a group meeting. These residents reported that the new Activities Director (AD) had not reviewed or explained their rights since assuming her role. A review of resident council meeting minutes from June to October 2024 confirmed that resident rights had not been discussed during this period. The AD, who became certified in March 2024, admitted she was unaware of the requirement to review resident rights during these meetings. The Operations Manager confirmed that while residents received a written copy of their rights upon admission, the AD was responsible for discussing these rights in meetings. The facility's policy mandates informing residents of their rights both orally and in writing.
Failure to Timely Report Roof Collapse Incident
Penalty
Summary
The facility failed to report an emergency situation to the state agency within the required timeframe. On 8/29/24, the roof of a secured locked unit collapsed due to a storm and insufficient covering during roof construction. This incident led to water pouring into the building, affecting the ceiling and various fixtures such as lights and smoke detectors. The Assistant Director of Operations (ADOR) discovered the situation when the fire alarm went off and observed water leaking from the sprinkler head and ceiling. The ADOR and other staff members promptly relocated residents from the affected unit to ensure their safety. Despite the severity of the incident, no residents were injured. The Director of Operations, who was temporarily filling in for the facility's administrator, was informed of the incident around 1:40 p.m. on the day it occurred. However, the incident was not reported to the State Survey Agency until after 6 p.m. on 8/30/24, exceeding the 24-hour reporting requirement. The Director of Operations mistakenly believed that reporting the incident within 24 hours of his notification was compliant with regulations. The facility's failure to report the roof collapse in a timely manner was a violation of the requirement to report emergency situations that pose a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canton Oaks | 13.6 mi | ★★★★★ | 0 | 0 |
| Avir At Grand Saline | 16.3 mi | ★★★★★ | 16 | 1 |
| Countryview Nursing & Rehabilitation | 16.3 mi | ★★★★★ | 23 | 1 |
| Azalea Trail Nursing And Rehabilitation Center | 16.8 mi | ★★★★★ | 1 | 0 |
| Terrell Healthcare Center | 16.8 mi | — | 43 | 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.