Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Potential for
minimal harm
Based on interviews and record review, the facility failed to ensure the residents received mail for 6 of 6
residents reviewed for rights to forms of communication. (Resident #s #9, #13, #28, #31, #44 and
Residents Affected - Many
#112).
The facility did not ensure residents received their mail promptly.
This failure could place the residents at risk of not receiving mail in a timely manner and a diminished
quality of life.
Findings included:
During an group interview on 07/11/2022 at 10:30 a.m., Residents #9, #13, #28, #31, #44 and #112 said
they did not know if mail was delivered on Saturday's. The residents said they only received mail Monday
through Friday.
During an interview on 07/11/2022 at 10:40 a.m., the Activity Director said she is not sure who handles the
mail on the weekend. She said the Receptionist brings her the mail during the week and she distributes it to
the residents. She said she is not sure how the mail is handled on the weekend.
During an interview on 07/12/2022 at 10:49 a.m., the weekday Receptionist said she received the mail
Monday through Friday, she sorts it and takes the remainder to the Business Officer Manager. She said the
Business Office Manager sorts it and gives her the mail for the residents and she takes that mail to the
Activity Director. The Receptionist said the weekend mail is collected by the weekend receptionist on
Saturday and locked in the desk drawer. She said when she arrives on Monday, she retrieves the mail,
sorts it, and she takes the remaining mail to the Business Office Manager. She said she receives the
residents' mail back from the Business Office Manager and takes it to the Activity Director for distribution.
During an interview on 07/12/2022 at 11:01 a.m., the Business Office Manager said she receives the mail
from the weekday Receptionist Monday through Friday. She said she sorts it and gives the residents' mail
back to the Receptionist to give to the Activity Director. She said Saturday mail is locked in the desk drawer
until Monday, when the weekday Receptionist gets it and brings it to her.
Record review of the facility's Policy/Procedure; Resident Rights and Responsibility Notice of: Privacy and
Confidentiality, dated 11/23/2016, revealed, 3. personal privacy, including the right to privacy in your oral
(that is, spoken), written, and electronic communications, including the right to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675597
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675597
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Health and Rehabilitation Center
1448 Houston St
Wills Point, TX 75169
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0576
promptly receive unopened mail and other letters, packages and other materials delivered to the facility for
you .
Level of Harm - Potential for
minimal harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675597
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675597
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Health and Rehabilitation Center
1448 Houston St
Wills Point, TX 75169
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that residents received and consumed
foods with the appropriate nutritive content as prescribed by the physician for 1 of 1 resident reviewed for
therapeutic diets. (Resident #45).
The facility did not prepare or serve a fortified food product to Resident #45 on 07/10/2022 and 07/11/22 as
indicated on the dietary slips and physician orders.
This failure could place residents at risk for weight loss and not having their nutritional needs met.
Findings included:
Review of Resident #45's physician's orders dated July 2022 indicated Resident #45 was an [AGE] year-old
female re-admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease,
psychotic disorder and weight loss. The orders indicated she was to receive a regular diet, pureed texture
on the fortified meal plan. She was also to receive Resource (liquid nutritional supplement) 120 ml three
times a day during the medication pass. The physician's orders indicated the resident was receiving
Remeron (mirtazapine) 7.5 mg. daily at bedtime for weight loss.
Review of Resident #45's annual MDS dated [DATE] indicated Resident #45 was severely cognitively
impaired, required extensive assistance of one staff with eating, and had unplanned weight loss.
Review of Resident #45's progress notes and weight logs indicated the following:
*On 05/09/2022 11:06 AM: Magic Cup and Resource 2.0 were discontinued due to a BMI of 24. The weight
log dated 05/05/2022 indicated Resident #45 weighed 140 lbs.
*On 06/01/2022 the weight log indicated the resident weighed 116.2 lbs.
*On 06/03/2022 11:05 AM: Resident #45 had Resource TID 120 ml for weight loss for 14 days. Resident
#45 was assisted with meals to encourage food intake. FMP for 7 days. The MD and family were notified.
The weight log dated 05/26/2022 indicated Resident #45 weighed 119.6 lbs. The Dietary Manager and
DON met for an interdisciplinary team meeting to address the weight loss, resident had eaten 75% of
breakfast, Resource 120 ml, FMP, MD orders entered and would continue to encourage the resident to eat.
The family notified.
*On 06/09/2022 01:22 PM: The MD was contacted, and an order was received for Remeron (appetite
stimulant) 7.5 mg orally at bedtime. The staff would continue to monitor weekly weights. Resident #45 was
on FMP and Resource 2.0.
*On 06/14/2022 03:37 PM the Registered Dietitian note indicated the resident had an order for FMP and
Resource 2.0 120 ml for 14 days. The new recommendation was to continue Resource 2.0 120 ml three
times a day for 90 days.
*On 06/23/2022 08:22 AM: Per the Dietitian's recommendation and physician's approval a new order
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675597
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675597
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/12/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crestwood Health and Rehabilitation Center
1448 Houston St
Wills Point, TX 75169
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0808
reflected Resident #45 had an order for FMP and Resource 2.0 120 ml for 14 days; and a recommendation
to continue Resource 2.0 120 ml three times a day for 90 days.
Level of Harm - Minimal harm
or potential for actual harm
*On 06/30/2022 03:35 PM the weight log indicated the resident weighed 120.4 lbs.
Residents Affected - Few
*On 07/05/2022 07:22 PM the weight log indicated the resident weighed 118.2 lbs.
*On 07/12/2022 10:45 AM the Registered Dietitian's note indicated weight loss, had ordered FMP and
Resource 2.0 120 ml three times a day. Resident #45 had 75-100% intake reported by staff. The new
recommendation was to increase Resource 2.0 to 240 mL three times a day.
During an observation on 07/10/2022 on the memory care unit at 12:30 PM, Resident #45's diet slip
indicated she was to receive fortified foods. Observation of Resident #45's meal reflected she did not
receive any fortified food items or extra butter. She received pureed baked chicken, baked beans and corn,
as well as chocolate pudding for dessert.
During an observation and interview on 07/10/2022 on the memory care unit at 12:39 PM, LVN A said she
let Resident #45 eat as much of her lunch by herself as she could, then she would help her a bit. LVN A
was observed feeding Resident #45 and the resident ate 100% of the food served.
During an observation of tray line service in the kitchen on 07/11/2022 at 11:50 AM, the holding
temperatures were taken on food prepared for the noon meal. The pureed items were ham, pinto beans,
and broccoli. There were no fortified foods prepared on the steam table. Resident #45's meal tray was on
the memory unit cart and left the kitchen at 12:08 PM and her tray did not contain a fortified food item.
During an observation on 07/11/2022 at 12:13 PM, Resident #45 did not receive any fortified food item or
extra butter. She received ham, pinto beans and broccoli in a pureed form. Her diet slip indicated she was
to receive fortified foods.
During an interview and observation on 07/12/2022 at 3:30 PM, the DM said the FMP consisted of extra
butter (3 pats) placed on the tray and the nursing staff were to mix it into the food. She said the dietary
department also prepared fortified items with extra butter and canned milk, like mashed potatoes and
pudding. She said other fortified products could be used like a Magic Cup (frozen nutritional treat), ice
cream, or health shake. She said oatmeal or cream of wheat at breakfast were prepared with extra butter
and canned milk, but all residents received the fortified hot cereal. She said the dietary department placed
the extra items on the trays. She said those were extra foods and did not replace a dessert or vegetable
that was part of the meal. She checked the evening meal trays for 07/12/2022 that were partially set up with
dietary slips and silverware and she pulled out Resident #45's meal tray and dietary slip. The dietary slip
indicated FMP. She said the cook was to prepare any fortified foods. The DM was asked for a resident
dietary roster, but it was not provided.
During an interview on 07/12/2022 at 3:35 PM, the DM asked [NAME] B if she had prepared any fortified
foods for the noon meals on 07/10/2022 and 07/11/2022. [NAME] B said she did not prepare any fortified
foods because she was not aware any resident was receiving fortified foods.
During an interview on 07/12/2022 at 5:15 PM, the DON said Resident #45 was receiving Resource 2.0 as
a nutritional supplement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675597
If continuation sheet
Page 4 of 4
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0344GeneralS&S Epotential for harm
Have an alternate power supply for its alarm system.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
FAQ · About this visit
Common questions about this visit
What happened during the July 12, 2022 survey of CRESTWOOD HEALTH AND REHABILITATION CENTER?
This was a inspection survey of CRESTWOOD HEALTH AND REHABILITATION CENTER on July 12, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CRESTWOOD HEALTH AND REHABILITATION CENTER on July 12, 2022?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have an alternate power supply for its alarm system."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.