Crestline Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Crestline Rehabilitation and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727May 27, 2026

  Based on the review of the staffing schedules, review of the timecard reports, and staff interview, the facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nursing (DON) on a full-time basis and further failed to ensure an RN was working in the facility at least eight consecutive hours per day, seven days a week. This had the potential to affect all residents. The facility census was 21.Findings include:Review of the facility staff schedules and the staff timecards for the week of 05/03/26 through 05/09/26 revealed a Registered Nurse (RN) did not work on 05/07/26 and 05/08/26. Further review revealed a Director of Nursing (DON) was not present in the facility on 05/05/26 through 05/09/26.Interview on 05/26/26 at 11:41 A.M. […]

• No harm, potential for more than minimal, widespreadF804Jun 18, 2025

  Based on policy review, observation, completion of a test tray, and resident and staff interviews, the facility failed to ensure food was served to the residents at palatable temperatures. This had the potential to affect 19 out of 21 residents who received meals from the facility. The facility identified two residents (#16 and #17) that received no food by mouth. The facility census was 21. Findings include: Observation of tray line on 06/18/25 from 7:25 A.M. through 7:58 A.M. revealed there was no pellet warmer, no plate warmer and food was above 164 degrees Fahrenheit (F) on the tray line. The food cart left the kitchen at 7:58 A.M. and arrived at the unit within a minute. Observation on 06/18/25 at 8:02 A.M. […]

• No harm, potential for more than minimal, widespreadF803Mar 14, 2024

  Based on observations, staff interview, and review of the menu and whiteboard, the facility failed to follow the prepared menus and failed to ensure the changes to the menu were approved by a qualified clinical nutrition professional for nutritional adequacy. This affected four of four meals reviewed during the survey. This had the potential to affect the 22 residents who received meals from the kitchen. The facility census was 24. Finding include: Review of the facility's menu for Fall and Winter 2023 to 2024 revealed they menu was signed but it was unknown who the person was because it was not the Registered Dietitian (RD) for the facility. The lunch menu for Wednesday 03/13/24 was chicken barbeque, macaroni and cheese, baked beans, and a peanut butter bar. […]

• No harm, potential for more than minimal, widespreadF880Jan 20, 2022

  Based on observation, medical record review, interview, and policy review, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) prior to entering a resident room who was on transmission-based precautions. This had the potential to affect all 21 residents residing in the facility. The facility census was 21. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physicians order dated 01/13/22, revealed Resident #25 was to be placed on droplet precautions for nine days following an exposure to COVID-19. Observation on 01/18/22 at 9:03 A.M. […]

• No harm, potential for more than minimal, patternF580Jun 18, 2025

  Based on resident and staff interview, record review, and review of the facility policy, the facility failed to timely notify the physician of the resident's changes in condition and/or abnormal laboratory results. This affected five (#4, #7, #16, #18, and #19) of five residents reviewed for notification of change. The facility census was 21. Findings include: 1. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included gastrostomy tube and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had gastrostomy, had a feeding tube, had weight loss, and was not on a prescribed weight loss regimen. Review of the care plan dated 03/19/25 revealed Resident #16 was at risk for impaired nutritional status. […]