Pennsylvania Department of Health
CRESTVIEW CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CRESTVIEW CENTER
Inspection Results For:

There are 152 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CRESTVIEW CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to one complaint completed January 22, 2026, it was determined that Crestview Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on review of clinical records, observation, and staff and resident interviews, it was determined that the facility failed to ensure timely assessment, identification, and documentation of a change in condition related to skin integrity for one of four residents reviewed (Resident R1). Review of facility policy "Skin Integrity and Wound Management", revised 2025, revealed "the nursing assistant will observe skin daily and report any changes or concerns to the nurse. The licensed nurse will: - Evaluate any reported or suspected skin changes or wounds; - Document newly identified skin/wound impairments as a change in condition; -Document skin/wound findings on the 24-hour Report; -Perform and document skin inspection on all newly admitted/readmitted patients weekly thereafter and with any significant change of condition". Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on July 10, 2024 with a diagnosis of brain neoplasm (brain tumor), epilepsy (brain condition that causes recurring seizures), and cortical blindness (total or partial loss of vision caused by brain damage to the occipital cortex). Review of Resident R1's most recent Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment Interview with Resident R1's family member on January 22, 2025 at 11:20 a.m., revealed Resident R1 had an unexplained bruise on his/her right inner forearm. Review of Resident R1's clinical record revealed Resident R1 was transferred to the hospital on January 02, 2025 and was re-admitted to the facility on January 05, 2025. Review of Resident R1's re-admission skin assessment, dated January 05, 2025, revealed no documentation of the presence of a bruise to Resident R1's right inner forearm. Review of Resident R1's clinical record revealed weekly skin assessments/wound care treatment were performed on the following dates: January 05, 2026 January 08, 2026 January 12, 2026 January 14, 2026 January 15, 2026 January 20, 2026 Review of Resident R1's physician orders revealed an order, dated January 05, 2025, for geri sleeve (protects sensitive thin skin from tears and abrasions) to be applied to left arm and to remove for skin check/treatment/hygiene. Observation of Resident R1 on January 22, 2026 at approximately 12:30 p.m. with Director of Nursing, Employee E1, present revealed Resident R1 with geri sleeve on his right and left arm. Director of Nursing, Employee E1, then performed a skin assessment on Resident R1's right lower inner forearm and identified a fading bruise. Interview on January 22, 2025 at 1:45 p.m. with Director of Nursing, Employee E1, confirmed there was no documentation that identified the bruise to Resident R1's inner forearm. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Plan of Correction - To be completed: 03/10/2026

F-0684 QUALITY OF CARE
S/S=D

Resident R1 had a skin check performed and bruise is documented.

Initial skin check audit to be conducted on current residents to ensure bruises are documented.

NPE or designee will re-educate licensed staff on Skin Integrity and Wound Management Policy.

DON or designee will conduct random weekly skin check audits on 10 residents x 4 weeks, then monthly x 2 to ensure newly identified bruises are documented.

Results of audits will be reviewed with the QAPI committee who will determine the need for further audits.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement