Inspection Reports for
Crestview Home
1313 SOUTH 25TH ST, BETHANY, MO, 64424-2634
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
191% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
43% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 40
Deficiencies: 22
Date: Mar 4, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, facility environment, staffing, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure lawful advance directives, maintain a safe and homelike environment, develop complete care plans, provide necessary assistance with activities of daily living, offer meaningful activities, timely blood transfusions, pressure ulcer care, range of motion services, adequate nutrition, safe respiratory care, proper use of bed rails, adequate staffing, staff education, posting of nurse staffing information, dietary management, food preparation, kitchen sanitation, infection prevention and control, and antibiotic stewardship.
Deficiencies (22)
Failed to ensure lawful advance directives for residents when Power of Attorney signed Do Not Resuscitate forms prior to residents being declared incapacitated.
Failed to maintain walls, hallways, ceilings, floors, furnishings, and dining room temperature in a clean, safe, and homelike environment.
Failed to develop and implement complete, accurate, and individualized care plans for residents addressing specific needs including elopement risk, pressure ulcers, wounds, and weight loss.
Failed to provide necessary assistance with activities of daily living including timely repositioning and perineal care for a resident dependent on mechanical lift.
Failed to provide meaningful activities and have an assigned activity director, resulting in residents being lonely and bored.
Failed to provide timely blood transfusion as ordered by physician, resulting in a 14-day delay.
Failed to provide appropriate pressure ulcer care including timely physician notification, wound assessments, documentation, and adherence to prevention protocols.
Failed to provide range of motion services or devices to prevent further loss of function for a resident with contracture.
Failed to provide ordered nutritional supplements (Magic Cup) daily, contributing to significant weight loss.
Failed to store nebulizer masks in bags when not in use for two residents.
Failed to document assessment, obtain consent, and conduct ongoing assessments for use of Halo side rails for one resident.
Failed to provide adequate staffing to meet resident needs including repositioning, incontinence care, showers, and meal assistance.
Failed to provide a Registered Nurse on duty for eight consecutive hours per day seven days a week.
Failed to ensure nurse aides had yearly performance reviews and individually based education plans.
Failed to post required nurse staffing information daily including census and actual hours worked.
Dietary Manager lacked required certification and training to manage food and nutrition services.
Failed to prepare and serve food in a form consistent with resident needs; pureed foods were thick with chunks or watery, mechanical soft foods were dry and hard to chew.
Failed to maintain kitchen and dish room in a sanitary manner including dirty sinks, floors, food storage on floor, unclean equipment, and missing dishwasher sanitizer logs.
Failed to follow infection control guidelines including administering eye drops without gloves and lack of water management plan to reduce Legionella risk.
Failed to establish an antibiotic stewardship program including protocols, monitoring, education, and designated staff.
Failed to designate a qualified Infection Preventionist responsible for infection prevention and control program.
Failed to ensure nurse aides had minimum 12 hours yearly in-service education including abuse, neglect, and dementia care.
Report Facts
Resident census: 40
Sampled residents: 12
Weight loss: 26.2
Weight loss percentage: 10.5
Blood transfusion delay: 14
Missing RN days: 38
Infections January 2025: 10
Infections February 2025: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in multiple interviews related to care findings and assessments |
| CNA C | Certified Nurse Aide | Named in interviews related to resident care and repositioning |
| Administrator | Facility Administrator | Named in interviews regarding staffing, policies, and expectations |
| Quality Assurance Nurse | Quality Assurance Nurse | Named in interviews regarding care expectations and deficiencies |
| Dietary Manager | Dietary Manager | Named in interviews regarding dietary services and food preparation |
| Registered Dietitian | Registered Dietitian | Named in interviews regarding dietary services and food preparation |
| Medical Director | Medical Director | Named in interview regarding staffing and resident care |
| Physician | Physician | Named in interview regarding blood transfusion orders and delays |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in wound care and resident assessments |
| Certified Medication Technician B | Certified Medication Technician | Named in interview regarding infection control and glove use |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Feb 19, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and comfortable environment, including issues with heating, maintenance, and cleanliness, as well as failure to provide timely physician-ordered care for a resident's blood transfusion.
Complaint Details
The complaint investigation was triggered by concerns about the facility's failure to maintain a safe and comfortable environment and failure to provide timely physician-ordered blood transfusion for Resident #7. The blood transfusion was delayed by 14 days after the order was placed, with communication and scheduling breakdowns identified.
Findings
The facility failed to maintain the physical environment in a safe and homelike condition, including inadequate heating in the dining room, poor maintenance of furnishings and building infrastructure, and cleanliness issues. Additionally, the facility failed to provide timely blood transfusion treatment for a resident, delaying the transfusion by fourteen days after the physician's order.
Deficiencies (3)
Facility failed to maintain walls, hallways, ceilings, floors, furnishings, and dining room temperature at a comfortable level.
Facility lacked maintenance supervisor for over a month, resulting in unresolved maintenance issues including cracked floor tiles, dust and debris in vents and light fixtures, damaged fire doors, gouged sheetrock, loose and missing handrail end caps, stained carpets, mold in shower room, and unclean surfaces.
Failure to provide timely blood transfusion for Resident #7, with a 14-day delay from physician order to transfusion.
Report Facts
Facility census: 40
Facility census: 43
Days delay: 14
Units of PRBC ordered: 2
Units of PRBC received: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reported facility had no maintenance supervisor for over a month and described maintenance and heating issues. | |
| Housekeeping/Laundry Aide A | Described cleaning responsibilities and lack of deep cleaning assignments. | |
| Quality Assurance Nurse | Reported maintenance struggles and lack of maintenance staff. | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Provided information on lab result handling and uncertainty about blood transfusion delay. |
| Physician's Registered Nurse (RN) A | Registered Nurse | Described physician orders for blood transfusion and communication with facility. |
| Business Office Manager (BOM) | Responsible for scheduling appointments and arranging transportation; acknowledged paperwork sometimes missed. | |
| Family Representative A | Reported resident fatigue and delay in blood transfusion. | |
| Family Representative B | Reported disagreement with facility over transportation for second blood transfusion. | |
| Physician | Expected blood transfusion to be carried out within 5-7 days of order. | |
| Director of Nursing | Expected physician orders to be carried out as soon as possible. |
Inspection Report
Routine
Census: 39
Deficiencies: 3
Date: Jun 24, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure ulcer care and prevention protocols, focusing on the care provided to residents at risk for pressure ulcers.
Findings
The facility failed to prevent compromised skin integrity for two sampled residents by not ensuring timely reporting of open and red skin areas to the charge nurse and not repositioning residents properly after care. Staff did not apply moisture barrier cream or offload pressure as required, resulting in minimal harm or potential for actual harm.
Deficiencies (3)
Failure to report open areas and red skin to the charge nurse immediately for Resident #1 and Resident #2.
Failure to reposition residents properly after care, leaving them on compromised skin areas.
Failure to apply moisture barrier cream to residents' red skin areas as per protocol.
Report Facts
Residents affected: 2
Census: 39
Open areas size: 0.5
Open areas size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Expected CNAs to report red and open areas immediately and reposition residents. |
| Director of Nursing | Director of Nursing | Expected CNAs to report red bottoms and open areas immediately and reposition residents to avoid pressure on compromised skin. |
| Administrator | Administrator | Expected staff to reposition residents every two hours and report red areas immediately. |
Inspection Report
Routine
Deficiencies: 13
Date: May 23, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, safety, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of medication holds, inadequate maintenance of resident rooms, incomplete care plans for psychotropic medication use, failure to provide scheduled showers, failure to respond appropriately to hypertensive crisis, unsecured medications, incomplete fall investigations and interventions, failure to monitor fluid intake for a resident on fluid restriction, poor communication with dialysis provider, failure to provide pneumococcal vaccination, unsafe kitchen equipment, and inadequate water management program to prevent Legionella.
Deficiencies (13)
Failed to notify physician when blood pressure medication was held for Resident #41.
Closet doors missing in Resident #13 and Resident #17's rooms, exposing clothing.
Failed to develop care plan addressing use of psychotropic medications for Resident #34.
Failed to provide showers as scheduled/preferred for Residents #34 and #37.
Failed to provide appropriate treatment for hypertensive crisis for Resident #32.
Failed to keep medication secure and failed to assess Resident #30 for self-administration safety.
Failed to thoroughly investigate fall and implement fall interventions for Resident #28.
Failed to monitor and record fluid intake for Resident #28 on fluid restriction.
Failed to communicate effectively with dialysis provider for Resident #28.
Failed to provide pneumococcal vaccine to Resident #8 despite consent.
Failed to maintain essential kitchen equipment in safe operating condition including walk-in freezer with ice buildup, broken oven door, and non-working steamer.
Failed to maintain a water management program to minimize Legionella risk in facility water supply.
Failed to specify target behaviors, monitor for adverse drug reactions, and complete behavior tracking for residents on antipsychotic medications (Residents #34 and #41).
Report Facts
Freezer storage bags: 50
Blood pressure readings: 189
Blood pressure readings: 113
Fluid restriction: 1500
Fall risk assessment: 1
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Interviewed regarding notification of medication holds and fall investigations. |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding fall interventions, fluid restriction monitoring, and dialysis communication. |
| CNA #7 | Certified Nurse Aide | Interviewed regarding medication security and shower provision. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication notification, behavior monitoring, dialysis communication, and vaccination. |
| Administrator | Facility Administrator | Interviewed regarding facility policies, maintenance, vaccination program, and overall compliance. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding facility maintenance and water management. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding kitchen equipment and food storage. |
| Medical Director | Medical Director | Interviewed regarding appropriateness of antipsychotic medication use. |
Inspection Report
Routine
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards, specifically focusing on the provision of showers as scheduled for residents and the sanitary storage of food.
Findings
The facility failed to provide showers as scheduled or preferred for two sampled residents, Resident #34 and Resident #37, with documentation and staffing issues contributing to the problem. Additionally, the facility failed to ensure leftover food was properly labeled, dated, and discarded, posing a risk to all residents receiving nourishment from the kitchen.
Deficiencies (2)
Failed to provide showers as scheduled/preferred for 2 of 5 sampled residents (Resident #34 and Resident #37).
Failed to ensure staff stored leftover food in a sanitary manner, including failure to label, date, and discard leftover food.
Report Facts
Residents affected: 2
Residents affected: 43
Number of freezer storage bags: 50
Dated freezer storage bags: 42
Undated freezer storage bags: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Interviewed regarding shower schedule and documentation for Resident #37. |
| CNA #1 | Certified Nurse Aide | Interviewed about staffing and shower provision. |
| CNA #2 | Certified Nurse Aide | Interviewed about shower schedules and resident care. |
| Nursing Assistant #12 | Nursing Assistant | Interviewed about Resident #37's refusal of care. |
| CNA #17 | Certified Nurse Aide | Interviewed about shower schedules and interactions with Resident #37 and Resident #34. |
| LPN #6 | Licensed Practical Nurse | Interviewed about shower refusal documentation and staff reporting. |
| RN #4 | Registered Nurse | Interviewed about Resident #37's shower refusals and whirlpool bath preferences. |
| HR staff member | Interviewed about shower sheet documentation and follow-up procedures. | |
| DON | Director of Nursing | Interviewed about shower scheduling and documentation. |
| Administrator | Administrator | Interviewed about shower refusal procedures and staff responsibilities. |
| Dietary Supervisor | Dietary Supervisor | Interviewed about leftover food storage and labeling. |
| Dietary Aide #15 | Dietary Aide | Interviewed about leftover food labeling and discard policies. |
| Dietary Manager Assistant | Dietary Manager Assistant | Interviewed about leftover food labeling and discard responsibilities. |
Inspection Report
Follow-Up
Census: 50
Deficiencies: 3
Date: May 10, 2023
Visit Reason
The inspection was a follow-up to verify correction of previously identified deficiencies related to maintenance and safety issues in the facility, including equipment repairs, call light system functionality, and environmental safety concerns.
Findings
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, including resident beds, lifts, and kitchen exhaust fans. The call light system was not functioning properly, leading to resident falls. The environment was unsafe and unsanitary with issues such as water damage, mold, broken plumbing, and deteriorated infrastructure. The facility lacked adequate maintenance staff and documentation of inspections.
Deficiencies (3)
Failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, including resident beds, lifts, and kitchen exhaust fans.
Call light system did not function properly, affecting residents on the 400 and 500 halls and contributing to falls.
Facility failed to provide a safe, functional, sanitary, and comfortable environment; issues included poor repair, malfunctioning HVAC, water leaks, mold, and deteriorated pipes.
Report Facts
Facility census: 50
Maintenance requests: 10
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide E | Certified Nurse Aide | Attempted to lock Resident #5's bed and reported lift issues |
| Dietary Manager | Dietary Manager | Reported kitchen exhaust fan not working |
| Administrator | Administrator | Interviewed multiple times regarding maintenance issues, call light system, and environmental concerns |
| Licensed Practical Nurse A | Licensed Practical Nurse | Reported call light system issues and environmental observations |
| Certified Nurse Aide C | Certified Nurse Aide | Reported call light system issues and maintenance delays |
| Certified Nurse Aide D | Certified Nurse Aide | Reported resident falls due to call light system failure |
| Marmic representative | Fire Alarm Vendor Representative | Explained call light system failure due to short circuit from a resident room |
| Business Office Manager | Business Office Manager | Reported sprinkler pipe break and roof leaks |
Inspection Report
Routine
Census: 57
Deficiencies: 18
Date: Aug 5, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, dietary services, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to maintain residents' dignity during meal service, improper management of resident funds, incomplete advance directive documentation, unsafe and unclean environment, incomplete and inaccurate care plans, medication administration errors, inadequate infection control practices, insufficient dietary management and staffing, poor kitchen sanitation, and lack of a functional quality assurance program.
Deficiencies (18)
Residents were served meals on Styrofoam plates, bowls, cups and plastic silverware, failing to maintain dignity.
Facility failed to provide receipts for Resident Trust Fund transactions and maintain signed authorizations.
Facility failed to ensure Out of Hospital Do Not Resuscitate forms were present and code status matched physician orders for sampled residents.
Facility environment was unclean with discolored floors, stains, holes in walls, and insufficient maintenance.
Care plans for sampled residents lacked comprehensive, measurable objectives and did not address all medical, nursing, and psychosocial needs.
Facility failed to follow procedures for medication administration and resident pass medication management, resulting in missed doses and medication errors.
Dependent residents did not consistently receive assistance with activities of daily living such as bathing and grooming.
Facility failed to assist a resident with obtaining prescription eyeglasses and maintain related records.
Staff failed to use proper lift sling and wheelchair brakes during resident transfer and failed to set low air loss mattress to correct weight setting.
Facility failed to ensure correct installation, use, and maintenance of bed rails and halos, including assessments, consents, and physician orders.
Facility failed to post accurate and current nurse staffing information daily.
Facility failed to employ a qualified dietary manager with accredited education in food service management.
Facility failed to ensure sufficient dietary staffing to serve meals timely and maintain kitchen cleanliness.
Facility failed to prepare pureed foods according to recipes and served pureed food more than 90 minutes before meal service.
Facility failed to follow physician's order for renal diet and served a regular diet to a resident requiring renal diet.
Facility failed to discard expired medications and biologicals, failed to ensure no food in medication refrigerators, failed to date opened medications and food, failed to record refrigerator temperatures, and failed to ensure no loose pills in medication cart.
Facility failed to follow infection control practices including staff not performing two-step TB testing for residents and employees, staff handling medications with bare hands, and improper hand hygiene during medication pass and blood glucose monitoring.
Facility failed to maintain an ongoing antibiotic stewardship program with monitoring and improvement plans.
Report Facts
Medication errors: 5
Facility census: 57
Temperature log entries: 14
Temperature log entries: 14
Pureed food temperature: 132.5
Pureed food temperature: 143.4
Pureed food temperature: 114.2
Pureed food temperature: 97.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication error and infection control findings related to medication handling and blood glucose monitoring. |
| Dietary Aide A | Dietary Aide | Named in findings related to dietary staffing, kitchen cleanliness, and pureed food preparation. |
| Interim Director of Nursing | Interim Director of Nursing | Named in multiple findings including infection control, medication administration, dietary services, and quality assurance. |
| Administrator | Administrator | Named in findings related to dietary management, kitchen cleanliness, quality assurance, and staffing. |
| Certified Medication Technician A | Certified Medication Technician | Named in medication administration and infection control findings. |
| Certified Medication Technician B | Certified Medication Technician | Named in medication pass and low air loss mattress findings. |
| Certified Nurse Aide B | Certified Nurse Aide | Named in grooming assistance findings. |
| Registered Dietician | Registered Dietician | Named in dietary and pureed food preparation findings. |
| Social Services Designee | Social Services Designee | Named in vision care and advance directive findings. |
| Transition Program Director | Transition Program Director | Named in medication pass and vision care findings. |
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