Crestline Rehabilitation and Nursing Center

Inspectors wroteBased on the review of the staffing schedules, review of the timecard reports, and staff interview, the facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nursing (DON) on a full-time basis and further failed to ensure an RN was working in the facility at least eight consecutive hours per day, seven days a week. This had the potential to affect all residents. The facility census was 21.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure enteral tube feeding was administered per physician orders. This affected one (#22) of three residents reviewed for enteral tube feeding. The facility identified three residents not receiving any food by mouth and on enteral tube feeding. The facility census was 21.

Inspectors wroteBased on policy review, observation, completion of a test tray, and resident and staff interviews, the facility failed to ensure food was served to the residents at palatable temperatures. This had the potential to affect 19 out of 21 residents who received meals from the facility. The facility identified two residents (#16 and #17) that received no food by mouth. The facility census was 21.

Inspectors wroteBased on resident and staff interview, record review, and review of the facility policy, the facility failed to timely notify the physician of the resident's changes in condition and/or abnormal laboratory results. This affected five (#4, #7, #16, #18, and #19) of five residents reviewed for notification of change. The facility census was 21.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to ensure the pharmacy recommendations had a rationale documented as to why the physician did not agree with the recommendation. This affected four (Residents #2, #15, #18, and #20) of five residents reviewed for unnecessary medications. The facility census was 21.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to ensure care plan meetings consisted of interdisciplinary team members determined by the residents' needs and failed to ensure the resident and/or resident representative were invited to attend the quarterly care conference meetings. This affected one (#3) of two residents reviewed for care plan meetings. The facility census was 21.

Inspectors wrote2. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included anoxic brain damage, retention of urine, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was dependent on staff for all activities of daily living and Resident #16 had an indwelling catheter. Review of the care plan last revised 04/07/25 revealed Resident #16 had an indwelling catheter. The goals included Resident #16 would show no signs or symptoms of urinary tract infections (UTI) through review date. Review of the infection log for the previous 12 months revealed Resident #16 had a UTI and received antibiotics on 08/26/24, 12/27/24, 03/10/25, and 04/16/25. Review of the physician orders for Resident #16 dated 01/13/25 revealed an order for catheter care every shift and as needed. Observation on 06/17/25 at 9:10 A.M. [...]

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure a resident was administered tube feeding through their percutaneous endoscopic gastrostomy (PEG) as physician ordered. This affected one (Resident #16) of one resident reviewed for tube feedings. The facility census was 21.

Inspectors wroteBased on observations, staff interview, record review, and review of the facility policy, the facility failed to ensure a resident was assessed for the need for oxygen use and receive oxygen per the physicians orders. This affected one (Resident #3) of one resident reviewed for oxygen use. The facility identified three current residents who received oxygen administration. The facility census was 21.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications ordered by the physician were ordered and available for administration. The affected one (Resident #4) of four residents reviewed for medications. The facility census was 21.

Inspectors wroteBased on observation, interview, record review, review of Medscape guidance, and review of the manufacturer directions, the facility failed to ensure the medication rate did not exceed five percent (%). There were two errors within 27 opportunities for an error rate of 7.41%. This affected two (Resident #16 and #24) of two residents reviewed for medication administration. The facility census was 21.

Inspectors wroteBased on observation, interview, record review, review of Medscape guidance, and review of the manufacturer directions, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #24) of two residents reviewed for medication administration. The facility identified eight residents who receive insulin. The facility census was 21.

Inspectors wroteBased on policy review, observation, and staff interviews, the facility failed to ensure food was served at proper consistency for mechanical soft and ground meat diets. This had the potential to affect three residents (#4, #8, and #21) that were ordered either a mechanical soft or ground meat diet. The facility census was 21.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure accurate documentation in the medical record for one (Resident #16) of 28 medical records reviewed.

Inspectors wroteBased on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) as ordered by the physician when completing high contact resident care activities with residents with indwelling medical devices and pressure ulcers. Additionally, the facility failed to follow the proper infection control practices during fingerstick checks and the shared glucometer was not properly cleaned and disinfected after use. This affected two residents (#16 and #24). The facility identified there were two residents who receive blood sugar checks utilizing the same glucometer and eight residents on EBP. The facility census was 21.

Inspectors wroteBased on observation, review of facility menus, and staff interview, the facility failed to ensure menus were followed. This affected all 19 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, and #22) residents who the facility identified as receiving meals from the kitchen. The facility census is 22.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure medications were not left unattended and unsecured in resident rooms. This affected one (#2) of three resident rooms observed. The facility census was 22.

Inspectors wroteBased on observations, staff interview, and review of the menu and whiteboard, the facility failed to follow the prepared menus and failed to ensure the changes to the menu were approved by a qualified clinical nutrition professional for nutritional adequacy. This affected four of four meals reviewed during the survey. This had the potential to affect the 22 residents who received meals from the kitchen. The facility census was 24.

Inspectors wroteBased on review of personnel files and staff interview, the facility failed to ensure the dietary manager met required qualifications to manage the dietary department. This affected 19 of 20 residents who received food from the kitchen. The facility census was 20.

Inspectors wroteBased on observation, resident interview, staff interview, review of facility menu, and review of food order invoice, the facility failed to follow the planned menu and failed to ensure alternatives were listed and approved by the dietician. This had the potential to affect 19 residents who received food from the kitchen. The facility's census was 20.

Inspectors wroteBased on medical record review, resident interview, staff interviews, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to report an allegation of resident-to-resident verbal abuse. This affected one (Resident #8) of two residents reviewed for abuse. The facility census was 20.

Inspectors wroteBased on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to complete a thorough investigation of an allegation of resident-to-resident verbal abuse. This affected one (Resident #8) of two residents reviewed for abuse. The facility census was 20.

Inspectors wroteBased on medical record review, observations, and staff interviews, the facility failed to ensure services were put into place to potentially prevent a decline in range of motion (ROM). This affected one (Resident #7) of one resident reviewed for ROM. The facility census was 20.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure blood pressure medication parameters were followed as ordered. Additionally, the facility failed to complete labs as for monitoring Coumadin use. This affected one (Resident #18) of give residents reviewed for unnecessary medication. The facility census was 20.

Inspectors wroteBased on medical record review, observation, staff interview, and review of medication information, the facility failed to ensure ordered antipsychotic medication was available for Resident #19. This affected one (Resident #19) of four residents reviewed for medication administration. The facility census was 20.

Inspectors wroteBased on medical record review, staff interview and review of facility protocol, the facility failed to provide appropriate treatment according to the bowel protocol for a resident. This affected one (Resident #18) of one resident reviewed for constipation. The facility census was 25.

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physicians orders to decrease the dosage of an antianxiety and antipsychotic medication resulting in an unobserved medication errors for Resident #1 and #5. This affected two (#1 and #5) of six residents reviewed for unnecessary medications. The facility census was 25.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to have a specific diagnoses or documented condition for the use of an antipsychotic medication for a resident. This affected one (Resident #1) of six residents reviewed for unnecessary medications. The facility identified seven residents as receiving antipsychotic medication. The facility census was 25.

Inspectors wroteBased on medical record review, facility policy review and staff interview, the facility failed to implement antibiotic stewardship protocols for Resident #1 and #24 receiving long term use of prophylactic antibiotics. This affected two (#1 and #24) of six residents reviewed for unnecessary medication. The facility census was 25.

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to place the recent survey results in an accessible place for resident and visitors to review without asking for staff assistance. This had the potential to affect all 25 residents residing in the facility.