Crestview Court

In the surveyor’s words

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

• Immediate jeopardy, patternF600Feb 21, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure resident was free from physcial abuse for 1 (Resident #1) of 7 residents reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. […]

• Immediate jeopardy, patternF607Feb 21, 2025

  Based on interview and record review the facility failed to implement the facility's own written abuse prevention policy and procedure for one (Resident #1) of seven residents reviewed for abuse. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. […]

• Immediate jeopardy, isolatedF773May 30, 2023

  Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #2) of four residents reviewed for labs. The facility failed to check the laboratory portal containing Resident #2's STAT (At once; immediately usually used in medical situations, to connote extreme urgency) lab results collected on 05/02/23. The physician was not notified of the abnormal results causing a delay in the physician ordering necessary interventions to treat the resident's infection. […]

• Actual harm, isolatedF689Sep 20, 2024

  Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for accidents. LVN A failed to provide supervision to prevent accidents when she continued to try to get urine sample after the resident said no, and knowing he was confused and angry, and that he required supervision to ambulate, she saw him get out of bed and closed the door on her way out. This resulted in the resident running down the hall after her and falling, sustain a serious injury. These failures placed the resident at risk for accidents and injuries. […]

• Actual harm, isolatedF684Apr 20, 2022

  Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to identify an ulceration to Resident #1's bottom of the right great toe. A family member discovered the ulceration on 11/29/2021, resulting in Resident #1 going to the podiatrist on 11/30/2021 and being diagnosed with an infected wound to the bottom of the right great toe. This failure placed residents with ulcerations at risk for worsening wounds, infection, or hospitalization . […]