Crestview Court

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts, Hall (200) and 4 of 4 residents (Residents #38, #40, #79 and #101) reviewed for pharmacy services and establish a system of records of receipt usage and disposition of all controlled drugs on the DON narcotic destruction locker reviewed for Narcotic Destruction record.1. The facility failed to ensure the 200 Hall nurses' medication cart contained accurate narcotic logs for Residents #38, #40, #79 and #101 on 06/17/26.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety reviewed for food safety. The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1. The facility failed to ensure food items in the walk-in refrigerator included an open date, best by date, an expiration date, were properly stored, sealed, and protected from exposure to air. These failures could place residents at risk for food-borne illness, cross contamination, and infection. During an observation on 06/16/2026 at 10:04 a.m., of the #1 handwashing sink's garbage receptacle the following was revealed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were accurately documented and complete in accordance with acceptable professional standards for 2 of 6 (Resident #13 and Resident #50) residents reviewed for advanced directives. The facility failed to ensure that an OOH-DNR was uploaded to Resident #13's EMR.The facility failed to ensure that an OOH-DNR was uploaded to Resident #50's EMR.The facility's failure could place the residents at risk of receiving unwanted life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 of 6 (Residents #6, Residents #15, and Residents #107) residents reviewed for clinical records. Resident #6's OOH-DNR record was incomplete. The date was missing from the Notary section. Resident #15's OOH-DNR record was incomplete. The date of one of two witnesses was missing in the Two Witnesses section. Resident #107's OOH-DNR record was incomplete. The dates were missing from Section C, the Two Witnesses section, and the Physician Statement section. The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 6 residents (Resident #9) reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #9. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one of three incidents (Resident #1) reviewed for reporting according to facility policy. CNA A failed to follow the facility's policy to report allegations of neglect when she failed to report Resident #1 fell over hitting her shoulder/neck on the bedrail when she reached for the wheelchair during attempted transfer, in which she did not use a gait belt, on 06/12/25. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. The facility failed to report an incident to HHSC involving CNA A failing to perform a safe, proper transfer using a gait-belt for Resident #1 which resulted in the resident bumping against the siderail. The failure placed residents at risk of injuries and neglect of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident (Resident #1) reviewed for supervision. CNA A failed to safely transfer Resident #1 from her bed to the wheelchair, which resulted in her losing her grasp of the resident and the resident bumping against the siderail. The failure placed residents at risk of injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the only facility medication room. These failures could place residents at risk for infection and having possible adverse effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety. 1. The facility failed to correctly label and date 4 storage bags of cheese. 2. The facility failed to correctly label a cart of water and juice stored in the refrigerator. 3. The facility failed to label and date packages of opened bread. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #52) of four residents reviewed for medication errors. The facility failed to ensure potassium (a mineral supplement used to treat or prevent low potassium levels in the blood) was administered to Resident #52 as ordered from 4/10/2025 until 4/23/2025 (13 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident was free from physcial abuse for 1 (Resident #1) of 7 residents reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. This failure could place residents at risk of abuse, injury, and emotional distress. [...]

Inspectors wroteBased on interview and record review the facility failed to implement the facility's own written abuse prevention policy and procedure for one (Resident #1) of seven residents reviewed for abuse. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. This failure could place residents at risk of abuse, injury, and emotional distress. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for two (Resident #1 and Resident #2) of four reviewed for resident call system, in that. 1. Resident #1 and Resident #2's call lights were on the floor and not within reach on 10/10/2024. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for one (400 hall cart) of four medication carts. The facility failed to lock the 400-hall cart leaving all medications on the carts accessible. These failures could affect all resident by placing them at risk for possible drug diversions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for accidents. LVN A failed to provide supervision to prevent accidents when she continued to try to get urine sample after the resident said no, and knowing he was confused and angry, and that he required supervision to ambulate, she saw him get out of bed and closed the door on her way out. This resulted in the resident running down the hall after her and falling, sustain a serious injury. These failures placed the resident at risk for accidents and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of three incidents reviewed for reporting. The facility failed to report within 2 hours to the State Survey Agency when Resident #1 had an altercation with LVN A which resulted in Resident#1 falling face first. Resident#1 was transported to the hospital with a major head injury which supports serious bodily injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system for two (Residents #24 and #48) of eight residents reviewed for resident assessments. The facility failed to ensure Residents #24 and #48's Admission, Quarterly and Annual MDS assessments was transmitted within 14 days after their MDS Assessments were completed. The MDS Assessments were not completed and submitted timely and accurately on 07/16/23, 10/17/23, 11/01/23, 11/16/23, 02/16/24 and 03/15/24. [...]

Inspectors wroteBased on interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Residents #189) of eight residents reviewed for Medical Records. The facility failed to ensure all of Resident #189's MDS Assessments dated 10/18/23 and 01/29/24 were coded accurately, that she was a female. The facility failed to ensure Resident #189's face sheet identified her as a female. These failures could affect residents by placing them at risk of not getting appropriate care and services due to the possible denial of payment for inhouse and outside services. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin were reported immediately to the State agency for one (Resident #6) of six residents reviewed for injuries of unknown origin. The facility failed to report to the State Survey Agency on 03/08/24, when Resident #6 was noted with an injury of unknown origin. This failure could place residents at risk for unreported abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one (Resident #6) of six residents reviewed for injury of unknown origin. The Administrator failed to start thoroughly investigating an injury of unknown origin when Resident #6 was discovered with fracture of proximal phalanx of left ring finger on 03/08/2024. Failure to timely investigate injuries of unknown origin placed residents at risk for unidentified abuse or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #76) of six residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan on 03/04/2024 to address Resident #76's need for assistance with Activities of daily living needs due to fracture. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis.