F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on observation, interview and record review the facility failed to report to state agency 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 for 1 of 1 secured locked unit reviewed for physical environment.
The facility failed to report to the State Survey Agency on 8/29/24 immediately but no later than 24 hours
after becoming aware the facility's roof collapsed on the secured locked unit.
This failure could place residents at risk of further potential abuse or neglect.
Findings included:
During observation of facility on 8/30/24 from 10:57am to 7:50pm a contract roofing company was working
on the roof, the locked unit was taped off due to not in use because of the damages caused by the roof
collapsing. All residents on 100 hall were relocated to the 200 hall and there was no visible bruising, skin
tears or marks. Residents did not show signs of fear when interacting with staff.
Record review of provider investigation report date 9/5/24 revealed: Date reported to HHSC - 8/3024 at
5:30pm. The incident date: 8/29/24; Time of incident: 1-6pm; Description of Allegation: Roof begun leaking
during a storm due to roof construction and lack of sufficient covering. Investigation Summary - Roof/ceiling
leak caused by rain while partial roofing was uncovered by contracted repair company. Fire panel restarted
within four hours. Fire alarm down in the secure unit (no residents on hall) during repairs - fire watch
ending.
During an interview on 8/30/24 at 2:06 p.m., the ADOR said he worked the day of the incident on 8/29/24
and it occurred a little after 1:00pm when the fire alarm went off, he said he walked around to see what was
going on and as he walked by the business office he saw water was dripping from the sprinkler head, he
placed a trashcan under the drip to catch the drip and at that time he said he assumed the sprinkler head
was just damaged. The ADOR said he continued down the hall and looked through the door window of the
secured locked unit and he saw water pouring from the ceiling on the main sitting area of the locked unit; he
said he started going room by room on the locked unit and at that time he witnessed the ceiling collapsed in
one of the rooms and he immediately at that time ran to the one bedbound resident who resided on the
locked unit and wheeled the bedbound resident's bed into the halls off of the unit and handed the resident
off to another staff. The ADOR said himself and several other staff started assisting the residents who
resided on the locked unit into the halls and to the main dining room outside the unit. He said water was
pouring into the building from anything that was attached to the ceiling for example the lights, smoke
detectors, the exit signs etc . The
(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 2
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
08/30/2024
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 0609
ADOR said none of the residents on the locked unit or in the building were hurt or received injuries.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 8/30/24 at 6:44 p.m., The Director of Operations said he had been filling in for the
facility's administrator for about a week. He said on 8/29/24 he started receiving several phone calls around
1:40pm, and throughout the afternoon regarding water pouring from the ceiling into the building on the
secured locked unit, he said he was coming from out of town because he was at a corporate meeting and
arrived around 6pm to the facility. The Director of Operations said he reported the incident to State Office
on 8/30/24 after 6pm and thought he was incompliance with reporting within the required 24-hour
timeframe, said he was not aware he had to report the incident to state office before 2pm because that was
when he was first notified of the incident .
Residents Affected - Few
Record review of long-term care regulation prover letter 2024-14 dated 8/29/24 provided by the facility as
the guidance they used reflected 1.0 Subject and Purpose: This letter provides guidance for reporting
incidents to HHSC and adds information about when providers must report communicable disease to
Complaint and Incident intake (CII). It also clarifies the types of events that are not reportable to HHSC, and
updates rule references. To aid providers in understanding the reporting requirements. 2.0 Policy Details
and Provider Responsibilities: 2.1 Incidents that a NF Must Report to HHSC - A NF must report to CII the
following types of incidents, in accordance with applicable state and federal requirements: .Emergency
situations that pose a threat to resident health and safety . 2.4 Reportable Incidents and Timeframes: . Do
Report: an incident that does not result in serious bodily injury but that involves any of the following:
.Emergency situations that pose a threat to resident health and safety When to Report: Immediately, but not
later than 24 hours after the incident occurs or is suspected.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675597
If continuation sheet
Page 2 of 2
