Crestview Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Dec 3, 2025

  Based on observation, staff interviews, clinical record review, and facility policy review, the facility failed to follow physician's orders for the treatment of a known facility acquired pressure ulcer and implement interventions to prevent a new pressure ulcer from developing for 1 of 2 resident (Resident #14) reviewed for pressure ulcers. Resident #14 admitted to the facility on Oct. 27, 2025, without pressure ulcers, and dependent on two staff assistance for bed mobility, transferring, and toileting assistance. Resident #14 assessed as at risk of the development of pressure ulcers. On Nov. 12, 2025, Resident #14 identified with a Stage 3 pressure ulcer on her sacrum. On Nov. […]

• Immediate jeopardy, isolatedF600Apr 19, 2023

  Based on clinical record review, staff interviews, and facility investigation review, the facility ailed to ensure staff protected and prevented potential abuse for 1 of 61 residents (Resident #5). The staff failed to identify an unknown male who entered the facility, spent an unknown amount of time with Resident #5, who was cognitively impaired, transferred the resident twice without assistance, then staff found the unknown male shirtless with his pants around his ankles, lying in bed with the resident; the resident observed to be crying. ). This failure resulted in possible distress for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. […]

• Immediate jeopardy, isolatedF689Apr 19, 2023

  Based on clinical record review, staff interviews, and facility investigation review, the facility failed to ensure staff provided adequate nursing supervision for 2 of 3 residents reviewed for accidents and hazards (Resident #5 and #1). The staff failed to identify an unknown male who entered the facility, spent an unknown amount of time with Resident #5, who was cognitively impaired , transferred the resident twice without assistance, then staff found the unknown male shirtless with his pants around his ankles, lying in bed with the resident; the resident observed to be crying. ). This failure resulted in possible distress for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. […]

• Actual harm, isolatedF684Dec 3, 2025

  Based on staff interviews, clinical record review, and facility policy review, the facility failed to assess and follow physician treatment orders for non-pressure wound care for 2 of 3 residents (Resident #29 and Resident #2) reviewed for assessment and intervention. The facility reported a census of 58 residents. Findings include: 1. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #29 admitted to the facility on Nov. 11, 2025. Resident #29 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. […]

• Actual harm, isolatedF689Dec 3, 2025

  Based on observations, staff interviews, clinical record review and facility policy review, the facility failed to use safe transfer techniques to prevent falls or injury for 3 of 4 residents (Resident #3, Resident #7, and Resident #50) reviewed for transfer techniques. Resident #3 experienced a fall out of a mechanical lift on 7/25/25, which resulted in a hematoma, sacral fracture and tibia fracture. The facility further failed to complete neurological assessments and check for range of motion of extremities, following a fall for 2 of 4 residents (Resident #7 and Resident #15) reviewed for accidents and hazards. The facility reported a census of 58 residents. Findings include:1. […]