Crestview Retirement Community

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from abuse and neglect on 05/03/2026 when CNA A verbally abused Resident #1 and neglected to give care when Resident #1 requested assistance to the bathroom. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 2 medication carts (Medication Cart #1) reviewed for drug storage and labeling. The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 36.36% based on 16 errors of 44 opportunities, which involved 2 of 5 residents (Resident #8 and Resident #10) observed during medication administration. 1. The facility failed to hold Resident #10's medication due to low heart rate. 2. The facility failed to ensure Resident #8's extended release (ER) medications were not crushed and the resident received the full dose of her medications. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its residents were free of any significant medication errors for one (Resident #8) of five residents reviewed for significant medication errors. The facility failed to ensure Resident #8's extended release (ER) medications, including Glipizide 2.5mg ER, Bupropion 300mg ER, and Metoprolol Succinate 50mg ER were not crushed prior to administration and that Resident # 8 received the full dose of her medications. These failures could place residents at risk of unwanted side effects, not receiving therapeutic dosage of medications, and ineffective disease management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products in the walk-in freezer that were past their facility indicated use by date. The facility failed to label and date food products in the walk-in freezer. The facility failed to clean their industrial can opener. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness.

Inspectors wroteBased 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. While the IJ was removed on 06/02/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1of 16 residents reviewed with limited range of motion (Resident #2), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #2 had interventions in place for her right- and left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right and left hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: [...]