Crestview Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 6, 2025

  Based on observations, staff interviews, family interview, clinical record review, hospital clinical record review, facility images, hospital images and policy review, the facility staff failed to ensure residents who required assistance to move around couldn't come into direct contact with the electric baseboard heater for 1 of 3 residents (Resident #1) reviewed. Resident #1 required the staff to utilize a mechanical lift to transfer in or out of the bed, needing significant assistance from the staff for all mobility. A staff member found Resident #1 with their legs laying on top of the electric baseboard heater on 12/8/24 at 12:44 AM. Staff interviews revealed Resident #1 potentially laid on the electric baseboard heater for approximately an hour before staff discovered him. […]

• Immediate jeopardy, patternF805Aug 29, 2023

  Based on observations, interviews and record review, the facility failed to serve the correct diets to 2 out of 59 residents (Resident #2 and Resident #28). During an observation of lunch service, Staff F, Cook, dished up a general diet for both Resident #2 and Resident #28. Resident #2 and Resident #28 were to receive mechanical soft diets (A type of texture-modified diet for people who have difficulty chewing and swallowing.) During the lunch service it was noted that another 6 residents were not on the Diet Type Report. Of these 6 residents, 4 of them did not have a Doctor's order for a diet (Resident's #20, #46, #64 and #65). These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 58. […]

• Actual harm, isolatedF686Jan 6, 2025

  Based on clinical record review, hospital clinical record review, hospital images, staff interviews and policy review, the facility failed to identify a resident with pressure ulcers/wounds and assure the resident received treatment and services, consistent with professional standards of practice, to promote healing of ulcers/wounds for 1 of 2 resident reviewed (Resident #1). The facility reported a census of 60 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. […]

• No harm, potential for more than minimal, widespreadF814Jun 22, 2022

  Based on observations, interviews, and record review, the facility failed to properly dispose of garbage and refuse, as evidenced by one of one dumpster that was overflowing, with trash and debris scattered on the ground. This had the potential to affect all residents by attracting pests. The facility reported a census of 46 residents. Findings included: On 6/20/22 at 9:40 AM observed a dumpster located in the parking lot approximately 20 feet from the back door to the facility, which led to the kitchen area. The dumpster had no lid and multiple bags of trash were piled high above the walls of the dumpster. During an interview on 6/20/22 at 9:45 AM, Staff I, Dietary Aide, stated the dumpster was emptied every Monday, Wednesday, and Friday. […]

• No harm, potential for more than minimal, isolatedF550Nov 17, 2025

  Based on observations, clinical record review, staff interview and policy review, the facility failed to treat residents (Resident #6 and Resident #18) with dignity during meal service. The facility reported a census of 58 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident had diagnoses of other orthopedic conditions, cirrhosis, renal insufficiency and non-Alzheimer's dementia. The MDS documented the resident required substantial/maximal assistance with eating. […]