Resident 40 fell from his wheelchair at 10:40 p.m. on May 27, 2024. When staff found him, his leg appeared deformed and he was "crying, moaning, guarding his left leg, grimacing, and unable to be consoled," according to federal inspection records. But instead of leaving him in place for emergency medical assessment, five staff members picked him up and placed him in bed.
Nurse 3 immediately called 911 after seeing the obvious injury. Then she reviewed the resident's chart, spoke with the Director of Nursing, and canceled the ambulance. The resident had advance directives stating he should not be hospitalized unless his "comfort needs could not be met at the facility."
Over the next 20 hours, Resident 40 remained in severe pain despite receiving scheduled and additional pain medications. When staff finally performed an X-ray the following day, it revealed an acute fracture of the proximal left femur. He was transferred to the hospital on May 28, where he was admitted for pain management.
Federal inspectors from the Centers for Medicare and Medicaid Services found the facility had committed immediate jeopardy violations - the most serious level of nursing home deficiency - for failing to provide effective pain management and proper emergency response. The violations occurred during a June 13, 2024 inspection.
The same facility faced another immediate jeopardy violation just days later when untrained staff performed CPR on a different resident.
On the morning of June 4, 2024, Resident 70 was found unresponsive in his bed. Three nurse aides began performing CPR without placing a backboard underneath him, which creates the hard surface needed for effective chest compressions. Two of the three aides, NA 3 and NA 4, were not certified in CPR for healthcare providers.
Surveyors observed the emergency response in real time. NA 3's compressions were so ineffective that Nurse 4 had to coach him, saying his compressions "were not deep enough" and "he needed to push harder to create recoil." When NA 3 responded that "he did not want to break Resident 70's ribs," staff had to replace him.
When Emergency Medical Services arrived at 9:55 a.m., the fire rescue captain immediately questioned why there was no backboard under the resident. Staff then struggled to remove the headboard from the bed to use as a makeshift backboard, initially unable to figure out that pins were holding it in place.
"This is a skilled nursing facility, and they should have the needed equipment in place when we get here," the fire captain told the Director of Nursing, according to inspection records. EMS continued rescue efforts but were unsuccessful. Resident 70 was pronounced dead at 10:13 a.m.
The facility's own policy required properly certified staff to provide CPR and mandated that supplies including a backboard be immediately available. But the crash cart was stored in a conference room due to construction, and staff didn't know where to find it.
NA 4 told inspectors his CPR certification had expired and he "did not do direct patient care very often because his main job was central supply." NA 3 said he had "only been employed at the facility for a short time and his CPR certification had expired and was no longer valid."
The Staff Development Coordinator, who had started just one week earlier, said she "thought it was better to start chest compressions without" a backboard "than to take the time to search the building for the backboard."
Beyond the immediate jeopardy violations, inspectors documented a pattern of care failures throughout the facility.
Staff failed to report suspected abuse when two nurses witnessed one resident cover another resident's mouth and pinch their nose closed until the victim's face turned red and their eyes rolled back. The incident occurred during shift change on June 28, 2024, but the facility never submitted required reports to state agencies or law enforcement.
Nurse 1 described seeing Resident 2 "reach up with his hand and cover her mouth" while Resident 1's "eyes began to roll back." Then Resident 2 "pinched Resident 1's nose closed using his thumb and index finger after which Resident 1's face started to turn red, and her head fell backwards."
Nurse 2 rushed to separate the residents and moved Resident 1 to safety. The victim later told staff she was "afraid of him and did not want to make him mad." When Nurse 2 assured her she was safe, "tears began to roll down the Resident's face."
The Administrator later acknowledged he "should have perceived the incident as abuse and followed the facility's abuse policy and procedures."
In another case, the facility refused to readmit a resident after sending him to the emergency department for psychiatric evaluation. Resident 346 had been admitted in late June 2023 with bipolar disorder, anxiety, and major depressive disorder. After displaying aggressive behavior and cutting himself with a soda can, he was transferred to the hospital on July 8, 2023.
When the hospital cleared him for discharge three days later, the facility's Admissions Coordinator refused to take him back, saying he needed inpatient psychiatric services. Hospital staff sent referrals to 50 other nursing homes but couldn't find placement. Resident 346 remained in the emergency department for eight additional days before being discharged home to elderly parents who were not physically able to care for him.
The hospital social worker told inspectors she had informed the facility that the resident "was cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued IVC had been reversed." The facility still refused readmission.
Basic care failures were documented throughout the facility. Resident 40, who suffered the fractured femur, was observed on multiple days with quarter-inch long fingernails caked with brown substance underneath. When a nurse aide was asked to observe the resident's fingernails, she "agreed that they were long, dirty, and needed to be cut and cleaned."
Another resident, Resident 78, had not received a haircut since December 2023 despite repeatedly asking staff and administrators for one. Her hair had grown so long it fell into her eyes and interfered with her ability to read and play bingo. The facility had not employed a beautician since at least August 2023.
"I am in need of a cut," Resident 78 told inspectors, showing them a photo of herself from six months earlier when her hair was "cut short and neatly styled."
Staff failed to provide prescribed oxygen therapy to multiple residents. Resident 40 was observed on three consecutive days without his ordered continuous oxygen, with the nasal cannula draped over his nightstand out of reach. When a nurse finally checked his oxygen saturation, it was 89 percent - below normal levels. After placing him on oxygen, his levels improved to 92 percent.
The facility also failed to properly secure indwelling catheters and maintain oxygen equipment. One resident's catheter tubing was repeatedly observed unsecured, causing her discomfort when it "pulled and tugged." Oxygen concentrator filters were observed "white with dust" for multiple days despite orders requiring weekly cleaning.
Federal inspectors issued immediate jeopardy citations for three separate violations: failure to provide effective pain management, failure to provide adequate treatment and care, and failure to ensure staff competency in emergency procedures. Additional violations were cited for abuse reporting failures, refusal to readmit eligible residents, inaccurate assessments, inadequate care planning, accident prevention failures, and respiratory care deficiencies.
The facility implemented corrective action plans and the immediate jeopardy violations were removed by mid-June 2024 after staff received additional training and new monitoring systems were put in place. However, the facility remained out of compliance at lower severity levels to ensure the corrections were sustained.
Crestview Health & Rehabilitation, operated by Accordius Health, has faced ongoing scrutiny over care quality and staffing issues. The facility serves residents requiring skilled nursing care and rehabilitation services in the Mooresville area.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestview Health & Rehabilitation from 2024-06-13 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Crestview Health & Rehabilitation
- Browse all NC nursing home inspections
