Crestview Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 19, 2021

  See event ID 5ME012 Based on record review and interview, the facility failed to provide adequate supervision for one resident (Resident #1), when the facility staff failed to implement interventions on 10/5/21 and 10/7/21 after the facility staff noted the resident displayed exit seeking behaviors and attempting to exit the facility unsupervised. On 10/8/21, at approximately 3:00 A.M., the facility was notified by the local hospital that the resident was at the hospital. The resident returned to the facility at 5:10 A.M. by the local police department. The resident was placed on one-on-one (1:1) supervision at that time. The facility failed to ensure staff carried out 1:1 interventions after the first elopement when the day shift staff did not continue the 1:1 supervision after 6:00 A.M. […]

• Immediate jeopardy, isolatedF689Jul 15, 2021

  Based on record review and interview, the facility failed to provide adequate supervision for one resident (Resident #1), when the facility staff failed to implement interventions on 10/5/21 and 10/7/21 after the facility staff noted the resident displayed exit seeking behaviors and attempting to exit the facility unsupervised. On 10/8/21, at approximately 3:00 A.M., the facility was notified by the local hospital that the resident was at the hospital. The resident returned to the facility at 5:10 A.M. by the local police department. The resident was placed on one-on-one (1:1) supervision at that time. The facility failed to ensure staff carried out 1:1 interventions after the first elopement when the day shift staff did not continue the 1:1 supervision after 6:00 A.M. […]

• No harm, potential for more than minimal, widespreadF801Mar 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 40. The facility did not provide the requested job description for the Dietary Manager. Review of the DM's personnel file showed: -Date of hire 10/04/2023; -No certification for food service management or dietary manager was found. During an interview on 02/24/25 at 11:32 A.M., the DM said: -He had been the DM for six months; -He has worked as a dietary aide, but does not have any managerial experience; -The facility was getting ready to start on his DM training; -He has not completed his/her DM's course. […]

• No harm, potential for more than minimal, widespreadF812Mar 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and to maintain the kitchen in a sanitary manner. The food facility census was 40. Review of the facility's policy, General Dish Room Sanitation, dated, May 2015, showed: -Dish rooms must be maintained in a clean and sanitary condition; -Items must be stored inverted (upside down) to prevent contamination. Review of the facility's policy, Cleaning Floors, dated, May 2015, showed: -Floors will be cleaned after every meal; -The dietary department must keep the floors of the kitchen free from soil and clutter. […]

• No harm, potential for more than minimal, widespreadF880Mar 4, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) which had the potential to affect all residents who resided at the facility. Furthermore, the facility failed to follow infection control guidelines when one staff administered eye drops for one resident (Resident #23) without the use of gloves. The facility census was 40. The facility did not provide a Legionella policy. 1. Review of the facility's records showed they did not have an implemented water management plan. During an interview on 2/25/25 at 3:50 P.M. […]