Crestview Manor Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684May 20, 2021

  Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The state agency determined these failures placed Resident #17 and other residents receiving fingerstick blood glucose monitoring and insulin coverage in an immediate jeopardy situation due to potential complications from [CONDITION(S)] resulting from failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted a plan of correction (POC) at 4:38 PM. The state agency requested changes and an additional POC was submitted at 4:50 PM. At 4:55 PM, the POC was accepted by the state agency. […]

• Immediate jeopardy, isolatedF689May 20, 2021

  Based on observation, staff interview, record review, and review of the Guidance for Industry and FDA (Food Drug Administration) Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06. The facility failed to ensure Resident #7's environment over which they had control was a free of accident hazards as possible. There was a 6.5 inch gap between Resident #7's mattress and her foot board creating an entrapment risk for Resident #7. The state agency determined this placed Resident #7 at an immediate risk for serious harm and or death related to entrapment. The facility was notified of the Immediate Jeopardy at 11:49 a.m. on 05/18/21. The facility submitted thier first plan of correction at 12:38 p.m. […]

• Actual harm, isolatedF689Jun 26, 2024

  49467 Based on record review, and resident, family, and staff interviews, the facility failed to provide the necessary supervision required to keep the environment for Resident #273 as free from accidents as possible, causing Resident #273 to have multiple falls in which she sustained multiple injuries. This was true for one (1) of three (3) residents reviewed for falls during the survey process. Resident Identifier: #273. Facility census: 69. Additionally, based on observation and resident and staff interview, the facility failed to keep the resident environment, over which it had control, was as free of accident hazards as possible, by leaving a potentially toxic substance on Resident #66's bedside table, making it accessible to other residents in the facility. […]

• No harm, potential for more than minimal, widespreadF880Sep 7, 2023

  Based on record review and staff interview the facility failed to ensure the Infection Prevention and Control Program (IPCP) policy and procedures were reviewed annually in accordance with the federal guidance and the facility assessment. This had a potential to affect all residents residing in the facility. Facility Census: 63 Findings included: a) IPCP policy and procedures During an record review on [DATE] at 9:00 AM the facility policies and procedures were not reviewed annually were as follows: -A facility policy and procedure titled Infection Prevention Program with a reviewed date of [DATE] -A facility policy and procedure titled CPR(Cardiopulmonary resuscitation) Guidance during the COVID-19 Pandemic with a reviewed date of [DATE]. […]

• No harm, potential for more than minimal, patternF804Feb 11, 2026

  Based on observation and interviews, the facility failed to ensure meals were served at a palatable temperature at time of delivery. This failed practice had the potential to affect more than a minimal number of residents residing in the long term care facility. Census: 69 Findings included:a) ObservationOn 02/10/26, a request was made of the Nursing Aides (NAs) on [NAME] wing to allow the State Agency (SA) to test the temperature of the last regular tray on the cart. The NA alerted the dietary manager (DM) to bring a new tray for the resident and a thermometer. […]