Resident 40 lay on the floor of his room at Crestview Health & Rehabilitation on May 27, 2024, at 10:40 pm when his roommate yelled for help. Five staff members responded: Nurses 1, 2, and 3, plus nursing assistants 1 and 2.
Nurse 1 and Nurse 2 rolled the resident over. Then all five staff members picked him up under his arms while nursing assistant 1 held traction to his left leg. They placed him back in bed.
Only then did Nurse 3 assess the resident and take his vital signs. She immediately noticed his left leg was internally rotated and shorter than his right leg. The resident was crying, moaning, guarding his left leg, grimacing, and could not be consoled by staff.
Nurse 3 called 911 and began printing transfer paperwork. But after reviewing the resident's chart and speaking to the Director of Nursing, she was instructed to cancel Emergency Medical Services. The resident had an advance directive indicating "Do Not Hospitalize" unless his comfort needs could not be met at the facility.
Instead, Nurse 3 contacted the on-call provider and received orders for a one-time dose of ibuprofen and a left hip x-ray. She administered that medication plus the resident's scheduled oxycodone at midnight. The resident continued grimacing in pain throughout her shift. She gave him another dose of oxycodone at 6:00 am.
The next day, Nurse 10 administered oxycodone at 12:19 pm and documented the resident's pain as 8 out of 10. An x-ray performed at the facility on May 28 revealed the resident had sustained an acute fracture of the proximal left femur.
The resident was finally transferred to the hospital on May 28, 2024, where he was admitted for further evaluation and pain management. The hospital noted obvious deformity in his left hip with inward rotation when he arrived.
"The facility staff always do things the way they are supposed to and follow protocol," said Physician Assistant 1, who saw the resident the next day. But she was unaware staff had moved him before assessing him. "If Resident 40's leg was stabilized she could not see a problem with moving him prior to performing an assessment and obtaining vital signs."
The PA was unfamiliar with the facility's protocol for assessing residents after falls. She received the x-ray results at 9:37 am on May 28 but had difficulty reaching the resident's representative to get permission to transfer him to the hospital, causing additional delay.
Nurse 3 said if she had arrived before the other staff moved the resident, "she would have instructed them not to move him until she had assessed him and obtained vital signs."
Nursing assistant 1, a former Emergency Medical Technician, said she held the resident's leg in traction during the transfer because Nurse 1 thought his leg was broken. But she did not function as an EMT at the facility.
The resident's roommate, who found him on the floor, told staff not to move him until EMS could assess him because he was afraid the resident's leg was broken. His warning was ignored.
Federal inspectors found this violated multiple safety standards and constituted immediate jeopardy to resident health. The facility failed to provide effective pain management and failed to transfer the resident to the hospital for pain that could not be managed at the facility, despite his advance directive allowing hospital transfer when comfort needs could not be met.
The Medical Director said nurses should perform a quick assessment to ensure a resident is breathing and has no obvious deformity before moving them. "If there was obvious deformity staff could cause additional harm to the resident," she said.
The Director of Nursing acknowledged staff could have caused additional harm if they moved a resident without assessment after a fall. She expected staff to assess for physical injury, deformity, pain, mental status changes, and obtain vital signs before moving anyone.
But she was not aware the staff had failed to assess Resident 40 before moving him. The facility had not investigated the incident because "they knew he had fallen."
The resident is deaf and mute with severe cognitive impairment. During an observation on June 4, he pointed to his left upper thigh, grimaced, and made a squeezing motion with his hands. He nodded yes that he had pain and mouthed that pain medication only helped a little.
Federal inspectors also found the facility failed to report and investigate suspected abuse between two residents. On June 28, 2024, during shift change, two nurses observed one resident cover another resident's mouth and pinch her nose closed. The victim's face turned red and her eyes rolled back.
Nurse 2 rushed to separate them. The victim had a look of shock and tears rolled down her face when staff assured her she was safe. She said she was afraid of the other resident and did not want to make him mad.
The Administrator was told about the incident that night but did not perceive it as abuse. He instructed staff to place the male resident on one-on-one observation but did not file required reports with the state agency, adult protective services, or law enforcement.
"In retrospect he should have perceived the incident as abuse and followed the facility's abuse policy," the Administrator said.
The facility also refused to readmit a resident after sending him to the hospital for psychiatric evaluation. Resident 346 cut himself with a soda can on July 8, 2023, and told staff "I am suicidal, and I want to go to the hospital."
After the hospital cleared him for discharge on July 11, a hospital social worker contacted the facility's admissions coordinator. The resident no longer required acute care or inpatient psychiatric services, and his involuntary commitment paperwork had been reversed.
The facility refused to take him back. The hospital sent referrals to 50 other skilled nursing facilities and could not place him anywhere. He remained in the emergency department until July 19, when he was discharged home with his elderly parents who were not physically able to care for him.
The Director of Nursing said she discharged him to the hospital "with the intent of not taking him back to the facility because she was worried about the safety of the residents and staff." She never followed up with the hospital and told the resident's family multiple times she would not accept him back.
The facility's responsible party became the primary caregiver while also caring for his spouse with end-stage Parkinson's disease and working full-time.
Other violations included failing to provide nail care for a resident with quarter-inch long fingernails with brown substance underneath, failing to provide haircuts for residents who requested them, and maintaining a medication error rate of 11.11 percent.
One resident had not received a haircut since December 2023 despite multiple requests to staff and administrators. Her hair fell into her eyes while reading and playing bingo. The facility had no beautician and no plan for providing haircuts to residents who needed them.
The immediate jeopardy finding was removed on June 12, 2024, after the facility implemented staff education and monitoring systems. But the facility remains out of compliance with federal care standards.
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
