Crestview Health & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Crestview Health & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 1, 2026

  Based on observations, record review, interviews, and facility policy review, the facility failed to ensure adequate action was taken to prevent abuse for seven of 25 residents (R) reviewed for abuse related to (1) allegations of sexual abuse to R9 and R20 by R10; (2) an allegation of sexual abuse to R8 by R7; (3) an allegation of physically abusive to R23 by R22; (4) an allegation of abuse to R2 by R3; (5) an allegation of abuse to R5 by R4; (6) an allegation of abuse to R1 by nurse aide (NA) 51. […]

• Immediate jeopardy, isolatedF610Mar 1, 2026

  Based on facility policy, record review, and resident, family, and staff interviews, the facility failed to complete a thorough investigation of allegations of abuse for 15 of 25 residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22 and R23) reviewed for abuse. The facility's failure to ensure that thorough investigations of abuse were conducted created the potential for residents to be, or to continue to be, abused, leading to serious physical and/or psychological harm for each resident.On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 2/26/2026 at 5:30 pm, the Administrator was… […]

• Immediate jeopardy, isolatedF835Mar 1, 2026

  Based on record review, policy review, and staff and resident interviews, the facility's administration failed to implement the abuse policies and procedures for 15 of 25 sampled residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22, and R23) reviewed for abuse. The facility's failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse. On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 2/26/2026 at 5:30 pm, the Administrator was notified that Immediate Jeopardy (IJ) was identified to have existed on 10/19/2025, when R9 made an… […]

• No harm, potential for more than minimal, patternF803Jun 5, 2025

  Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate meal portions as outlined on the menu for the regular texture and puree texture meals. This failure placed 226 residents who received a regular or pureed diet, out of 305 total residents, at risk for weight loss, nutritional problems, and dissatisfaction with their meals. Findings include: Review of the undated Diet Order Tally Report, provided by the facility on 06/05/25, revealed there were 186 residents who received a regular diet and 40 residents who received a pureed diet. Review of the undated Week 3 Thursday lunch menu, provided by the facility revealed the menu called for: -4 ounces (oz) of green beans for the regular texture meals; -4 oz. […]

• No harm, potential for more than minimal, patternF600Jul 25, 2024

  Based on observations, staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from neglect for four of four residents (R) (R3, R4, R5, and R6) reviewed for neglect. Specifically, R3, R4, R5, and R6 had care plan interventions in place for one-to-one supervision and monitoring but did not receive one-to-one supervision and monitoring. The deficient practice resulted in R3 being found on the floor and sent to the hospital for evaluation, and had the potential for R4, R5, and R6's care and needs not being addressed. […]