Crestline Rehab: No Director of Nursing for Weeks - OH
Federal inspectors who visited the 21-resident facility on May 26 and 27 found that the previous Director of Nursing had quit on April 29. What followed was nearly a month of rotating nurses who each believed someone else was handling the job.
A licensed practical nurse told inspectors on May 26 that the facility had two people filling the director role on a part-time basis. One came on Wednesdays. The other came two days a week. Beyond that, the LPN said she could not recall anyone else serving as director since the last one walked out.
When inspectors asked a registered nurse on staff that same morning, she said the current Director of Nursing was a woman identified in the report as RN, DON #84. Then she said she had no idea how often that person was actually in the building, and suggested asking the LPN, because the LPN was around more.
The next morning, inspectors sat down with RN, DON #84 herself. She identified herself as the Regional Nurse. She said she does not punch a clock. She also said she had no documentation showing she had worked in the facility at any point since the previous director left on April 29.
A second nurse, RN, DON #82, told inspectors she had been in the building exactly twice since early May, on the 13th and the 20th, both Wednesdays. She had not worked there at all during the week of May 3 through May 9.
A third nurse, RN, DON #83, said the only day she had set foot in the facility was May 4. She did not return for the rest of that week.
That left May 5 through May 9 with no Director of Nursing present at all. Inspectors confirmed it by pulling staff schedules and timecard records. The Director of Operations, identified as DOO #86, verified the gap when interviewed on May 27. He acknowledged that RN, DON #82 was supposed to be serving as director but had only been in the building those two Wednesdays. He confirmed there was no director coverage from May 5 through May 9.
He also confirmed something more immediate. On May 7 and May 8, there was no registered nurse in the facility at all.
Not a fill-in. Not someone working remotely. Nobody.
Twenty-one residents were in that building on those two days with no RN present, in a facility that is required to have one working at least eight consecutive hours every single day.
When inspectors asked for the facility's written policy on Director of Nursing coverage and RN staffing hours, RN, DON #84 told them the facility did not have one. She said they follow the regulation instead.
The regulation they were following required a full-time DON and daily RN coverage. The records showed neither had been in place for weeks.
The inspection was conducted in response to a complaint. Inspectors classified the harm level as minimal or potential, a designation that reflects the absence of documented injury to residents, not the absence of risk. A facility with 21 residents and no registered nurse on duty for two consecutive days, and no nursing director for five, has no one in a position to catch a deteriorating wound, a medication error, or a resident in distress and make the call that requires a license to make.
The Director of Operations knew the director position was vacant. The Regional Nurse knew she had no records of being there. The nurses cycling through on scattered days knew someone else was supposed to be handling it. What none of them had was a plan that actually kept a registered nurse in the building every day, or a director in charge every week.
The previous director had been gone for nearly a month by the time inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestline Rehabilitation and Nursing Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
CRESTLINE REHABILITATION AND NURSING CENTER in CRESTLINE, OH was cited for violations during a health inspection on May 27, 2026.
Federal inspectors who visited the 21-resident facility on May 26 and 27 found that the previous Director of Nursing had quit on April 29.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.