Crestview Health & Rehab Ctr

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure adequate action was taken to prevent abuse for seven of 25 residents (R) reviewed for abuse related to (1) allegations of sexual abuse to R9 and R20 by R10; (2) an allegation of sexual abuse to R8 by R7; (3) an allegation of physically abusive to R23 by R22; (4) an allegation of abuse to R2 by R3; (5) an allegation of abuse to R5 by R4; (6) an allegation of abuse to R1 by nurse aide (NA) 51. The facility's failure to ensure no further abuse was perpetrated created the potential for residents to be, or to continue to be, abused, leading to serious physical and/or psychological harm for each resident. [...]

Inspectors wroteBased on facility policy, record review, and resident, family, and staff interviews, the facility failed to complete a thorough investigation of allegations of abuse for 15 of 25 residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22 and R23) reviewed for abuse. The facility's failure to ensure that thorough investigations of abuse were conducted created the potential for residents to be, or to continue to be, abused, leading to serious physical and/or psychological harm for each resident. On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, policy review, and staff and resident interviews, the facility's administration failed to implement the abuse policies and procedures for 15 of 25 sampled residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22, and R23) reviewed for abuse. The facility's failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse. On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. On 2/26/2026 at 5:30 pm, the Administrator was notified that Immediate Jeopardy (IJ) was identified to have existed on 10/19/2025, when R9 made an allegation that a male resident, R10, sexually abused her by touching her in between her legs on that date. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure psychotropic medications were not given before informed consent or risk versus benefits for three of eight residents (R) (R11, R12, and R13) reviewed for psychotropic medications. This failure had the potential for ordered psychotropic medications provided without evidence of informed consent, which included treatment goals, benefits vs risks, and adverse reactions to treatment.

Inspectors wroteBased on review of facility policy, record review, and family and staff interviews, the facility failed to ensure appropriate social services assistance was provided for one of 25 sampled residents (R) (R18). The facility's failure to ensure the provision of social services assistance for R18 created the potential for this and other residents to experience harm related to having unmet psychosocial needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation Procedures, the facility failed to protect residents from resident to resident physical abuse for two of four sampled residents (R) (R5 and R4). Specifically, R5 was hit by R4.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation Policy and Procedures, the facility failed to protect residents from misappropriation of property for one resident (R) (R3) by not ensuring that R3's gold teeth were placed in a secure location.

Inspectors wroteBased on record review, resident family and staff interviews, and review of the facility policy titled, Transfer and Discharge (including AMA 'against medical advice'), the facility failed to provide a 30-day notice to three of seven sampled residents (R) (R3, R6, and R7) or their representatives before they were discharged from the facility.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Minimum Data set MDS Completion, the facility failed to complete accurate MDS assessments for three of seven sampled Residents (R1, R2, and R7). The deficient practice had the potential for R1, R2, and R7's care needs to go unmet.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure adequate meal portions as outlined on the menu for the regular texture and puree texture meals. This failure placed 226 residents who received a regular or pureed diet, out of 305 total residents, at risk for weight loss, nutritional problems, and dissatisfaction with their meals.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the call device was accessible for one of 41 residents (Resident (R) 286) observed for call light accessibility in the Initial Pool. This failure placed R286 at risk of accident, injury, or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure a splint was applied to address a hand contracture for one of one resident (Resident (R) 6) reviewed for limited range of motion out of a total sample of 39. This failure had the potential to lead to increased contracture, pain, or skin breakdown for R6.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the medical record reflected accurate medication administration times for one of 39 sample residents (Resident (R) 157). This failure had the potential to lead to missed or late doses of insulin, which could cause hyperglycemia or other complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from neglect for four of four residents (R) (R3, R4, R5, and R6) reviewed for neglect. Specifically, R3, R4, R5, and R6 had care plan interventions in place for one-to-one supervision and monitoring but did not receive one-to-one supervision and monitoring. The deficient practice resulted in R3 being found on the floor and sent to the hospital for evaluation, and had the potential for R4, R5, and R6's care and needs not being addressed.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for four resident rooms (Room A1-117, A1-128, B1-131, and B2-201) on three of six halls (Hall A1, B1, and B2). Specifically, these rooms contained peeling/hanging ceiling paint above the toilet area, unattached and damaged ceiling border, broken bathroom wall tiles, exposed molding material, damaged wall pole pipe cover, and dirty damaged Packaged Terminal Air Conditioner (PTAC) units. The facility census was 278 residents. Initial observation on 3/05/2024 at 11:16 am in room A1-117 revealed bathroom ceiling paint was peeling/hanging above the toilet area. Observation on 3/6/2024 at 10:00 am in room A1-117 revealed bathroom ceiling paint was peeling/hanging above the toilet area. [...]

Inspectors wroteBased on observations, interviews, and review of the facility policy titled Respiratory Care Services, 3.3A Simple Oxygen Therapy Adults and Pediatrics, the facility failed to administer oxygen (O2) therapy per physician order for three of 20 residents (R) with orders for continuous O2 (R92, R152, and R242). The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Glucometer Disinfection, the facility failed to maintain proper infection control measures by not disinfecting a blood glucose sampling device after using on one of 58 sampled residents (R) (R196) and before preparing it for use on another resident. The deficient practice had the potential to spread infection.

Inspectors wroteBased on observation, record review, staff interviews, and review of facility policies 'Oxygen Administration' and 'Tracheostomy Care', the facility failed to have emergency tracheostomy supplies readily available at the bedside, failed to have Physician orders for tracheostomy care and oxygen for four of 12 residents (R) (R#39, R#232, R#867, and R#181) with tracheostomies.

Inspectors wroteBased on interviews and record review, the facility failed to honor resident rights related to personal fund for one of 91 sampled residents (R) (R#92). The facility did not obtain written permission from the R#92 or his Responsible Party (RP) to become the representative payee of his Social Security check thus preventing the R#92 or his RP from managing his personal funds.

Inspectors wroteBased on clinical record review, staff interviews, review of the facility's policy Resident Rights Regarding Treatment and Advanced Directives Policy and review of facility document titled Crestview Health and Rehabilitation Center Advanced Directive Notification the facility failed to ensure that the health records, which included the physician orders and care plan, accurately reflected the code status wishes for one of 91 sampled residents (R) (R#74).

Inspectors wroteBased on observations and staff interview, the facility failed to the facility failed to ensure that it was maintained in a safe, clean and comfortable environment related to an electrical outlet observed in one room.

Inspectors wroteBased on observation, record review, staff interviews and the facility policies titled, Medication Administration Policy and Care and Treatment of Feeding Tube Policy the facility failed to follow acceptable infection control practices for two of 91 sampled residents (R) (R#214 and R#77) related to (1) improper handling of medications for R#214 and (2) proper technique while providing tube feeding for R#77.