Crest Nursing Home

In the surveyor’s words

From the most serious findings on record at Crest Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 8, 2021

  Based on observation, interview, and record review, the facility failed to implement person centered interventions for falls, appropriately assess the resident after a fall; failed to put individualized measures into place to prevent future falls, one of which resulted in a major injury, for 1 (#25) of 3 sampled residents. Findings Include: During an observation and interview on 3/2/21 at 7:50 a.m., staff member F stated resident #25 was found on the floor this morning, and nurses were doing hourly neuro checks because the fall was unwitnessed. Resident #25 was observed to have his left arm bandaged, and was sitting in a chair as the nurse handed him his medications. […]

• No harm, potential for more than minimal, widespreadF727May 7, 2026

  Based on interview and record review, the facility failed to ensure a Director of Nursing (DON) worked full-time (defined by CMS as 40 hours or more per week) as the Director of Nursing. This failure increased the risk of negative outcomes for all residents. Findings include:During an interview on 5/4/26 at 12:30 p.m., staff member A stated the facility employed a full-time Director of Nursing and did not have any nurse staffing waivers in place.During an interview on 5/7/26 at 10:20 a.m., staff member B stated she is the infection preventionist and also the DON. Staff member B stated she dedicated 20 hours per week to infection control and the rest of her time to director of nursing responsibilities. […]

• No harm, potential for more than minimal, patternF600May 7, 2026

  Based on interview and record review, the facility failed to protect a vulnerable resident from non-consensual sexual contact by a resident #22, who had a with a history of sexually inappropriate behaviors, for 1 (#1); and failed to monitor physical and psychosocial harm for 1 (#18) after an incident of abuse by resident #43, of 5 residents sampled for abuse by another resident. This failure resulted in resident #1 having her breast groped and bruising to resident #18's head and neck. Findings include:1. […]

• No harm, potential for more than minimal, patternF658Mar 25, 2025

  Based on interview and record review, the facility failed to ensure licensed nursing staff adhered to accepted standards of practice by only administering oxygen within the parameters of provider's orders for 3 (#s 4, 5, and 6) of 3 sampled residents prescribed supplemental oxygen. Findings include: 1. Resident # 5 Review of resident #5's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 03/12/2024 RESPIRATORY TREATMENT: Oxygen 1lpm via NC to maintain Sp02 >90% for hypoxemia.at bedtime NOC noc O2 Sat: AM am O2 Sat: PM pm O2 Sat. […]

• No harm, potential for more than minimal, patternF695Mar 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure a portable oxygen tank was replaced when the metered volume was empty, with the resident's oxygen saturation at 86%, for 1 (#6); and failed to ensure licensed nursing staff documented provider notification, nursing assessments, and/or nursing interventions of resident's oxygen saturation levels below the parameters set forth in written orders of 90% for 2 (#s 5 and 6) of 3 sampled residents receiving supplemental oxygen. Findings include: 1. Resident #6 During an observation on 3/24/25 at 11:17 a.m., resident #6 was seated in her wheelchair, in the hallway, outside of her room. Resident #6 had a portable oxygen tank attached to her chair, which showed the pressure gauge needle at approximately 1,500 psi. […]