Crestpark Dewitt, LLC

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, it was determined that the facility did not have a Registered Nurse (RN) at least eight consecutive hours a day for seven days a week.

Inspectors wroteBased on facility document review and interview, it was determined that the facility failed to submit the quarterly Payroll Based Journal (PBJ) information for the period of October 2025 - December 2025, to the Centers for Medicare and Medicaid Services (CMS). Specifically, the quarterly data was not submitted, per the established schedule.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure a staff's hair was contained while preparing and serving food, and staff used proper hand hygiene while preparing and/or serving a meal.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 36 residents.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends for 1 (Residents #20) sampled resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure potential hazardous chemicals were secured and stored behind a locked door.

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed psychotropic medication, Lorazepam, was not continued past 14 days without a physician's documented rationale and duration for 1 (Resident #30) sampled resident reviewed for as needed (PRN) psychotropic medication.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to maintain a medication error rate of less than 5% to prevent complications for 2 (Residents #10 and #15) sampled residents observed during medication pass resulting in medication errors.

Inspectors wroteBased on observation, record review, and interview, the facility failed to consistently implement a system to accurately reconcile and dispose of a controlled liquid narcotic, Lorazepam, 90 days after the bottle was opened, according to the manufacturer's instructions on the bottle for 1 (Resident #5) sampled resident who was reviewed for disposition of Lorazepam.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide a pneumonia vaccine for 2 (Residents #1 and #20) of 5 residents reviewed for immunizations.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to coordinate with the state designated office to get a Preadmission Screening and Resident Review (PASARR) evaluation for a resident to ensure the resident received designated services for 1 (Resident #19) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided to toenails for 1 (Resident #20) sampled resident reviewed for nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered rate for 1 (Resident #20) sampled resident reviewed for oxygen (O2) use and failed to provide a policy and procedure for respiratory care and services according to professional standards of practice.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately account for a controlled liquid narcotic, Lorazepam, after narcotic being administered to 1 (Resident #5) sampled resident who was reviewed for pharmaceutical services.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure the nurse checked the heart rate for 1 (Resident #10) sampled resident prior to the administration of a medication used to treat a heart condition by slowing down the heart rate and making sure the heart beats stronger resulting in a significant medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN), was on duty for 8 consecutive hours a day seven days a week.

Inspectors wroteBased on observation, interview and policy review, the facility failed to store, prepare, and serve food for residents in a safe and sanitary manner in 1 of 1 kitchen in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to change oxygen (O2) tubing and continuous positive airway pressure (CPAP) tubing for 1 (Resident's #27) of 3 (Resident's #4, #5, and #27) residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in a secure location under the manufacturer's specified conditions, to ensure accuracy and quality of medication administration and ensure medications were secure for one of one medication rooms.

Inspectors wroteBased on observations, interview and record review the facility failed to keep Resident's rooms free and clean of pest droppings, dead bugs, and cobwebs to maintain a clean and homelike environment.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 (Resident #37) of 4 (Resident #3 Resident #8, Resident #13,) sampled residents that were reviewed for unnecessary medication did not receive a PRN (as needed) medication pass 14 days without justification, and an evaluation by the doctor.