Crestview Retirement Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 2, 2023

  Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervisions and assistive devices for 1 of 8 Residents (Resident #17) reviewed for accidents and hazards, in that: Facility failed to adequately supervise and ensure staff checked the coffee temperature prior to serving to residents which resulted in Resident #17 spilling a pot of coffee over his lap resulting in 1st and 2nd degree burns to his bilateral thighs and down his legs to his ankles. On 05/31/2023 at 2:40 PM an Immediate Jeopardy (IJ) was identified. […]

• Actual harm, isolatedF578Oct 16, 2021

  Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR for one (Resident #1) of 44 residents reviewed for advanced directives, in that: Resident #1 was found unresponsive in his room and nursing staff did not have Resident #1's correct code status in Resident #1's EMR and performed CPR on resident. Resident #1 was revived and sent by ambulance to the hospital where he was intubated until his RP was contacted and told the hospital to cease all life saving measures per the DNR. Resident #1 passed in the hospital that same afternoon. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in one of one walk in refrigerator. The facility failed to label and date leftover, opened foods in the walk-in refrigerator in the kitchen. This failure could place the residents at risk of foodborne illness and decreased quality of life. Findings included: In an observation on [DATE] at 10:05 AM in the main kitchen in the walk-in refrigerator revealed an uncovered rolling shelve with meat on metal trays not covered or dated; one full metal tray of barbeque chicken; one full metal tray of baked chicken, on metal tray with a pork tenderloin not covered, dated, or labeled. […]

• No harm, potential for more than minimal, patternF700Aug 7, 2025

  Based on observation, interview and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 6 of 12 (Residents #1, #5, #6, #7, #20 and #40) residents reviewed for bed rails. The facility failed to assess Residents #1, #5, #6, #7, #20 and #40 for entrapment from bed rails or obtain documentation of informed consent before using bed rails on the residents' beds. This failure could place residents at risk of injury from entrapment. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2025

  Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 kitchens (main kitchen) reviewed for food safety. 1. The facility failed to ensure the ED and DRM wore a hair restraint while in the kitchen on 08/05/25. 2. The facility failed to ensure the DM wore gloves while preparing prepared ham sandwiches in the kitchen. These failures could place residents at risk of food-borne illness. Findings include: 1. Observation on 08/05/25 at 09:20 AM revealed the ED, who had short hair, and the DRM, who had shoulder length hair, standing in the kitchen and speaking to the cooks. Neither of them wore a hairnet or hair restraint. […]