Crestview Center

In the surveyor’s words

From the most serious findings on record at Crestview Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 14, 2023

  Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R5 was free from sexual and physical abuse. This failure resulted in an Immediate Jeopardy situation for Resident R5 whose arm was restrained and was sexually abused by Resident R6 for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the Center prohibits abuse, mistreatment, neglect, misappropriation of resident'/patient property, and exploitation for all patients. […]

• Immediate jeopardy, isolatedF656Jul 14, 2023

  Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to developed a plan of care for a male resident (Resident R6) who was seeking attention from female residents and staff. This failure resulted in Resident R6 engaging in inappropriate sexual contact with a female resident placing Resident R5 and other residents in an Immediate Jeopardy situation for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the facility is to . […]

• Actual harm, isolatedF600Jul 1, 2026

  Based on review of clinical records, facility policy, facility documentation, and interviews with residents and staff, it was determined the facility failed to ensure one of four residents reviewed was free from sexual abuse, resulting in psychosocial harm including being diagnosed with Post Traumatic Stress Disorder (Resident R1). This deficiency was identified as past noncompliance. Findings include: Review of facility policy titled, Abuse Prohibition revised 2025, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. […]

• Actual harm, isolatedF686Mar 16, 2026

  Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to timely identify and implement interventions to ensure that Resident R1 did not develop pressure ulcers. This failure resulted in actual harm to Resident R1 who developed an unstageable sacral pressure ulcer requiring hospitalization for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy Skin Integrity and Wound Management, revised 2025, revealed staff are to perform comprehensive initial and ongoing assessments of factors affecting skin integrity, develop care plans reflective of assessment findings, and implement as well as revise interventions as needed to prevent skin breakdown. […]

• Actual harm, isolatedF600Mar 11, 2026

  Based on clinical record reviews, review of facility documentation and interviews with staff, it was determined the facility failed to ensure Resident R1 was free from neglect related to failing to provide wound treatment in accordance with physician orders. This failure resulted in actual harm for Resident R1 who developed an infection of the left foot surgical site, for one of nine residents reviewed. This deficiency was cited as past non-compliance. (Resident R1). Findings include: Review of facility policy titled Abuse Prohibition, revised November 14, 2025, indicates Neglect is defined as the failure, indifference, or disregard of the center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm,… […]