Crestview Specialty Care

Inspectors wroteBased 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. 13, 2025, the primary care provider issued orders for wound treatments, an air mattress, and repositioning every 2 hours. During an observation on Nov. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain a clean environment and resident equipment. The facility reported a census of 58 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to provide enough qualified staff members to provide nursing and related services to meet the specific, individualized needs for 1 of 2 residents reviewed for sufficient staff (Resident #6). The facility reported a census of 58 residents. 1. The Minimum Data Set (MDS) Assessment for Resident #6 dated 6/13/25, reflected a Brief Interview for Mental Status (BIMS) of 9 out of 15, indicating moderate cognitive impairment. The MDS identified Resident #6 required moderate assistance for toileting, bathing and personal hygiene. Resident #6 is frequently incontinent and the resident is not on a toileting program. [...]

Inspectors wroteBased on observations, staff interviews and facility policy review the facility failed to ensure the infection control practices of hand hygiene during the administration of insulin and wound care, and the use of Enhanced Barrier Precautions utilized as required to reduce the transition of multidrug resistant organisms during high contact resident care for 3 of 4 residents (Resident #2, Resident #14, and Resident #41) reviewed for infection control. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide a respectful, dignified environment and care to 3 out of 10 residents reviewed (Residents #14, #16, and #44). The facility reported a census of 58 residents. Findings Include:1. The Minimum Data Set (MDS) Assessment for Resident #16 dated 9/26/25, revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #16 dependent on staff for toileting, personal hygiene and meeting physical needs related to immobility. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to obtain consent for an antipsychotic medication for one out of five residents reviewed for unnecessary medications (Resident#6). The facility reported a census of 58 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility policy review, the facility failed to provide twice weekly bathing for 4 of 5 resident (R#6, R#29, R#43, and R#60) and failed to provide assistance with incontinence cares for 1 of 5 residents (Resident #15) reviewed for activities of daily living (ADLs). The facility reported a census of 58 residents.

Inspectors wroteBased on staff interviews, employee file review and facility policy review the facility failed to complete 3 out of 3 employee annual reviews. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, staff interviews and facility policy review the facility failed to remove expired medication from 1 out of 2 medications carts and failed to check the medication refrigerator temperatures on 1 out of 2 refrigerators on a scheduled basis. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, facility document review, staff interviews and facility policy review the facility failed to post the daily staffing for 4 out of the 6 days of the survey. The facility reported a census of 58 residents.

Inspectors wroteBased on staff interview, facility document review and review of the Summary Statement of Deficiencies, the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to prevent repeated quality deficiencies identified during the current recertification survey. The facility reported a census of 58 residents.

Inspectors wroteBased on observation, clinical record review, policy review and staff interview the facility failed to prevent the recurrence of a pressure ulcer for 1 of 2 residents reviewed (Resident #27). The facility reported a census of 54 residents.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy review the facility failed to respond to call lights within 15 minutes for 4 of 4 residents reviewed (Res #6, #12, #50, #204) and the facility failed to staff according to the Facility Assessment for seven out of eleven days reviewed. The facility reported a census of 54 residents.

Inspectors wroteBased on observations, facility policy review and staff interviews the facility failed to use hand hygiene during a noon meal service in an attempt to prevent cross contamination of food. The facility reported a census of 54 residents.

Inspectors wroteBased on facility policy review, and staff interviews the facility failed to have an Infection Preventionist who completed specialized training in infection prevention and control. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility notification documents, and staff interviews the facility failed to notify the Office of the State Long-Term Ombudsman (OSLTO) of two separate resident transfers to the hospital for 1 of 3 residents reviewed for hospitalizations (Resident #2). The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to administer medication as the physician ordered for one of three residents reviewed. (Resident #2).

Inspectors wroteBased on observation and resident and staff interviews, the facility failed to respect personal property and possessions when they searched the resident's room without consent for one of three residents reviewed. (Resident #3). The facility reported a census of 54 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility failed to accurately assess resident conditions and implement appropriate interventions in a timely manner for 2 of 9 residents reviewed for accurate assessment. [...]

Inspectors wroteBased on observations, resident and staff interviews, and facility policy review the facility failed to maintain a clean and safe environment as evidenced by broken glass in a picture frame and an unknown substance on a surface in the dining room. The facility reported a census of 58 residents. Findings Include: 1. On 1/29/24 at 10:32 AM, an observation of the dining room revealed a dresser with 3 milky white areas that contained yellowish pea sized raised areas. The white areas were 3 inches by 2 inches, 1 inch by 1.5 inches, and and 1.5 inches by .5 inches in size in addition to rings of milky white substance the shape of a round container. A small area of white spots lay 3-4 inches from the ring. The raised sections appeared bumpy and fuzzy. At 2:19 PM some of the substance had been removed from the surface, including the raised areas. An area 1.5 inches by .75 inches remained. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy review, the facility staff failed to provide proper cares after toileting residents for 1 of 6 residents reviewed for personal cares (Resident #104). The facility reported a census of 58 residents. Findings Include: During the survey, Resident #104 noted without a completed Minimum Data Set (MDS) Assessment. A review of Resident #104's Electronic Medical Record (EMR) revealed the following diagnoses: Congestive Heart Failure, Stage 3 Pressure Ulcer of the right buttock and Metabolic Encephalopathy. On 1/25/24, the Care Plan identified Resident #104 with the problem of needs assistance with activities of daily living and required staff assist of one for personal hygiene and toileting. The Care plan failed to direct staff on use of the proper technique to provide proper perineal care after toileting. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to follow proper infection prevention policies regarding indwelling catheters for one of four residents reviewed (Resident #49). The facility reported a census of 58 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #49 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and had the following diagnoses: Orthopedic Aftercare, Atrial Fibrillation (an abnormal heart rhythm) and Fracture of the left femur. The MDS documented Resident #49 was dependent on staff for most activities of daily living. [...]

Inspectors wroteBased on clinical record review, staff and physician interviews, and facility policy review, the facility failed to notify the physician of a change in wound characteristics for 1 of 5 residents reviewed for a change in condition(Resident #14). The facility reported a census of 55 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 10/29/23, listed diagnoses for Resident #14 which included heart failure, diabetes, and osteomyelitis(inflammation of the bone). The MDS documented the resident required partial/moderate assistance for toileting, showering, upper body dressing, rolling left and right, sitting to lying, sitting to standing, transferring, bathing, and walking, and substantial/maximal assistance with lower body dressing, putting on and taking off footwear, and lying to sitting. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to assess and intervene after a change in condition for 1 of 4 residents reviewed for a change in condition (Resident #1). The facility reported a census of 55 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 10/3/23, listed diagnoses for Resident #1 which included Parkinsonism (a disorder of the central nervous system that affected movement and often caused tremors), malnutrition, and balanitis (inflammation of the penis). The MDS documented the resident required partial/moderate assistance for eating and oral hygiene and substantial/maximal assistance for toileting, showering, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, and sitting to standing. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff, Physician and Nurse Practioner interviews, the facility failed to ensure timely provider notification of a skin anomaly and the timely initiation of a treatment for 1 of 3 residents reviewed for pressure ulcers (Resident #1). The facility reported a census of 55 residents. Findings Include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). [...]

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interviews, the facility failed to ensure a resident's safety while utilizing rehabilitation equipment for 1 of 6 residents reviewed for supervision (Resident #6). The facility reported a census of 55 residents. Findings Include: The 7/24/23 Minimum Data Set (MDS) Assessment Tool, dated 7/24/23, listed diagnoses for Resident #6 which included muscle weakness, difficulty walking, and cancer. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and listed the resident's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. A 7/21/23 Care Plan entry identified the resident at risk for falls and stated the resident required a safe environment without clutter. [...]