Crestline Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review for Resident #24 revealed an admission date of 03/27/25. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had diabetes mellitus and received insulin injections. Review of the care plan dated 03/28/25 revealed Resident #24 had diabetes mellitus type two with hyperglycemia. Interventions included accuchecks as ordered and administer medications. Review of the physician orders for Resident #24 dated 06/05/25 revealed insulin Lispro injection solution 100 units/milliliter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review for Resident #24 revealed an admission date of 03/27/25. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had diabetes mellitus and received insulin injections. Review of the care plan dated 03/28/25 revealed Resident #24 had diabetes mellitus type two with hyperglycemia. Interventions included accuchecks as ordered and administer medications. Review of the physician orders for Resident #24 dated 06/05/25 revealed insulin Lispro…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Observation on 06/18/24 at 7:37 A.M. revealed [NAME] #223 plated Resident #21's plate with sausage gravy and it was placed into the food cart. Dietary Manager (DM) #210 was asked to remove Resident #21's food tray from the food cart. Resident #21's sausage gravy was of regular consistency with the sausage cut into 1/2 inch pieces. DM #210 verified Resident #21's was on a mechanical soft diet and the meat should have been ground. DM #210 proceeded to put Resident #21's tray back into the food cart, then paused and grounded some sausage gravy for Resident #21 and the other mechanical and ground diets. The telephone interview on 06/18/25 at 11:49 A.M. with Speech Therapist #303 revealed it was her expectation to have ground meat like hamburger…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review for Resident #16 revealed an admission date of 09/14/22. Diagnosis included anoxic brain damage, gastrostomy tube, dysphagia, and paraplegia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had gastrostomy tube. Review of the physician orders for Resident #16 revealed an order for nothing by mouth (NPO) diet related to gastrostomy status dated 09/14/22; Cerovite advanced formula liquid (multivitamin), give five teaspoons by mouth one time a day dated 03/15/25; Vitamin C 500 milligrams (mg) by mouth once daily dated 03/16/2; and Acetaminophen tablet 325 mg give two tablets by mouth every four hours as needed for pain dated 12/02/24. Observation of medication administration on 06/17/25 at 8:04 A.M. revealed LPN #224 administered Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included acute and chronic respiratory failure, gastrostomy tube, pressure ulcer left and right buttocks stage four (Full thickness tissue loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the lunch menu for Friday, 05/03/24, identified baked fish, macaroni and cheese, creamy coleslaw, bread and butter, and Jello poke cake were planned to be served. Observation of the kitchen meal service on 05/03/24 at 11:50 A.M. revealed [NAME] #5 was observed to plate resident meals with fish, macaroni and cheese, creamy coleslaw, and Jello. The observation identified meal cart #1 left the kitchen on 05/03/24 at 12:00 P.M. and none of the trays included bread and butter as listed on the menu. Interview with Cooperate Dietary Manager #10 was completed on 05/03/24 at 12:05 P.M. in the hallway as the staff started delivering meal trays to the residents. Corporate Dietary Manager #10 confirmed the meal trays did not include bread…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of Resident #2's medical record identified her admission to the facility occurred on 12/19/20 with medical diagnosis including malnutrition, depression, pancreatic tumor, and esophageal stricture. The most recent comprehensive assessment completed on 03/04/24 identified Resident #2 was completely cognitively intact. Observation and interview with Resident #2 on 05/03/24 at 10:41 A.M. revealed a full cup of oral medications sitting on the resident's bedside stand with a cup of pudding. Interview with Resident #2 at that time confirmed the nursing staff usually set her medications down and leave them with her, and stated sometimes she just throws them in the trash. Review of Resident #2's medication administration record (MAR) for May 2024 revealed the residents morning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Finding include: Review of the facility's menu for Fall and Winter 2023 to 2024 revealed they menu was signed but it was unknown who the person was because it was not the Registered Dietitian (RD) for the facility. The lunch menu for Wednesday 03/13/24 was chicken barbeque, macaroni and cheese, baked beans, and a peanut butter bar. The white board (located in the hallway near the residents' rooms) revealed the residents would be receiving hamburger gravy, mashed potatoes, green beans, and pudding. The dinner menu for Wednesday 03/13/24 was taco salad, refried bean, lettuce and tomato, crackers, and cream pie. The white board revealed the residents were to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the personnel file for Dietary Manager (DM) #36 revealed a hire date of 12/01/21. Further review of the file revealed no evidence DM #36 was a certified dietary manager, certified food service manager, or had similar national certification for food service management and safety, or had an associates or higher degree in food service management. Interview on 08/24/22 at 11:26 A.M. with the Business Office Manager (BOM) #37 verified DM #36 did not have any required training or certifications for the dietary manager position. Interview on 08/24/22 at 9:46 A.M. with Registered Dietician (RD) #69 revealed she worked at the facility 32 hours per month. Interview on 08/24/22 at 12:03 P.M. with DM #36 confirmed he previously worked in a restaurant prior to being hired at the facility in December 2021. DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Interview on 08/22/22 at 8:48 A.M. Resident #14 reported residents were not given menus to see what was served for meals to determine if they wanted the meal served or an alternative. Resident #14 stated if she was served a meal she did not like, she would order an alternative and have to wait until the meal was served to all residents before alternatives could be made. Alternatives were typically cold meat sandwiches. Review of the menu for 08/22/22 revealed lunch to be served was crispy baked chicken with sweet potatoes. Observation on 08/22/22 at 12:05 P.M. of Resident #14's lunch revealed mashed potatoes and diced chicken mixed with gravy was served, rather than the crispy baked chicken with sweet potatoes as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Medical record review revealed Resident #8 admitted to the facility on [DATE] and was cognitively intact. Review of the progress note dated 05/29/22 at 11:51 A.M. revealed Resident #8's roommate (Resident #10) was upset, cursing, and using racial slurs toward Resident #8 due to Resident #8's television (TV) volume. The nurse entered the room and Resident #10 reported he could not sleep due to Resident #8's TV volume. Resident #10 told the nurse, You're not doing me any good, so just get out. The nurse informed the residents she was unable to leave due to the altercation and for the safety of all parties. Resident #10 then turned over to go to sleep. The Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Medical record review revealed Resident #8 admitted to the facility on [DATE] and was cognitively intact. Review of the progress note dated 05/29/22 at 11:51 A.M. revealed Resident #8's roommate (Resident #10) was upset, cursing, and using racial slurs toward Resident #8 due to Resident #8's television (TV) volume. The nurse entered the room and Resident #10 reported he could not sleep due to Resident #8's TV volume. Resident #10 told the nurse, You're not doing me any good, so just get out. The nurse informed the residents she was unable to leave due to the altercation and for the safety of all parties. Resident #10 then turned over to go to sleep. The Director of Nursing (DON) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of Resident #7's medical record revealed an admission dated on 12/17/17 with a diagnosis of stroke. Review of the Minimum Data Set (MDS) assessments dated 04/04/22 and 07/01/22 revealed Resident #7 had limitations in ROM to one side of her body and required a restorative program and use of a splint. Review of the occupational therapy discharge instructions dated 04/04/22 identified a new splint was ordered for Resident #7's left hand and left ankle to assist with prevention of a decline in ROM. The starting goal was to wear the splints for 40 minutes a day. Observations on 08/22/22 at 8:32 A.M., 9:56 A.M., 12:19 P.M., and 3:22 P.M. revealed Resident #7's splint device for her left hand remained on a stand across the room. Resident #7 was not observed wearing the splint. Observations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of Resident #18's medical record identified an admission date of 05/22/19 with medical diagnoses including atrial fibrillation, obesity, congestive heart failure and diabetes. Review of Resident #18's physician orders for August 2022 revealed an order for Lisinopril (medication used to treat blood pressure and heart failure) 30 milligrams (mg), twice a day (BID). There were parameters in place to hold the Lisinopril if the resident's systolic blood pressure was less than 120. Review of Resident #18's August 2022 medication regime included Lisinopril 30 mg BID (twice a day). The physician order for the Lisinopril had parameters to hold for a systolic blood pressure (top number of the blood pressure) less than 120.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of Resident #19's medical record revealed an admission date of 08/01/22 with medical diagnoses including bipolar disorder, adjustment disorder, lymphedema, obesity and chronic respiratory failure. The record identified Resident #19 had physician ordered Abilify 5 mg tablets twice a day for treatment of psychiatric disorders. Review of Resident #19's physician orders for August 2022 revealed an order for Abilify (antipsychotic) 5 milligrams (mg), twice per day for treatment of psychiatric disorders. Observation, interview, and record review of medication administration on 08/23/22 at 8:15 A.M. revealed Registered Nurse (RN) #31 was preparing medications for Resident #19. RN #31 reported Resident #19's Abilify was not available in the medication cart.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, major depressive disorder and insomnia . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/03/19, revealed the resident had severe cognitive impairments. She required total assistance of one person for toilet use. She was always incontinent of bowel and bladder. Review of the plan of care, last updated 07/08/19, revealed Resident #18 had bowel incontinence due to immobility, severe intellectual disabilities and a history of constipation. The interventions included checking the resident frequently and assisting with personal hygiene as needed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbances, delirium and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, the resident has short and long term memory loss. There was no psychosis, rejection of care, behaviors or psychotic diagnoses documented on the MDS. Review of the plan of care, dated 03/12/19, stated the resident uses psychotropic medications Risperdal (antipsychotic) due to diagnosis of dementia/delirium. The interventions include monitoring, documenting and reporting adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbances, delirium and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, revealed the resident had short and long term memory loss. No psychosis, rejection of care, behaviors or psychotic diagnoses were documented on the MDS. Review of the plan of care, dated 03/12/19, stated the resident used psychotropic medication Risperdal (antipsychotic) due to diagnosis of dementia/delirium. The interventions included monitoring,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/19, revealed the resident has short and long term memory loss. Review of the plan of care, last revised on 06/07/19, stated Resident #1 has a history of frequent urinary tract infections with long term use of antibiotics. The goal was for the resident to be free of urinary tract infections. The interventions included giving the antibiotic as ordered to prevent urinary tract infections and monitor any change. Review of the monthly physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.