Crestline Rehab: Feeding Tube Failures Over Three Months - OH
Nobody caught it until a complaint triggered an inspection.
Resident #22 depends on a feeding tube. That means staff are responsible for confirming the tube is correctly placed before feeding begins, checking residual fluid in the stomach to make sure the body is absorbing what it receives, and delivering the exact volume a doctor has prescribed. On multiple dates across December 2025 and January and February 2026, records show the facility did neither the first thing, nor the second, nor the third.
On February 6 and February 19, the night shift did not document that anyone checked feeding tube placement before administering nutrition. On February 6, night shift staff also skipped the residual check entirely. Across the three-month span, there were multiple dates where no documentation existed at all for how much tube feeding Resident #22 received.
On the days when amounts were recorded, the numbers swung between 30 milliliters and 2,420 milliliters. The physician's order set a specific volume. The facility's own records show that on multiple dates across all three months, what was actually given did not match what the doctor had ordered.
The registered nurse director of nursing, identified in inspection records as RN DON #84, confirmed all of it during an interview on May 27 at 1:10 p.m. She verified the missing documentation. She verified the inconsistent volumes. She verified that on multiple dates, the amount recorded as administered was not consistent with the physician's order.
The facility's own enteral nutrition policy, last revised in January 2014, states that adequate nutritional support through enteral feeding will be provided to residents as ordered. The gap between that written commitment and what the records showed ran for at least ninety days.
A feeding tube is not a passive device. Placement can shift. If a tube migrates and feeding continues, nutrition can enter the lungs instead of the stomach, a condition that can cause aspiration pneumonia and, in vulnerable patients, death. Residual checks exist to catch dangerous buildup before it becomes a crisis. Volume consistency matters because tube-fed residents cannot self-regulate, cannot feel full and stop eating, cannot tell a nurse that something feels wrong. The safeguards that exist in a feeding tube protocol exist precisely because the resident cannot provide them.
The inspection was triggered by a complaint, logged under complaint number 2789196, and completed May 27, 2026. CMS classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The finding appears on page two of a three-page deficiency statement.
What the report does not say is what, if anything, happened to Resident #22 during those three months. Whether the fluctuations in volume caused discomfort, weight loss, or something worse. Whether anyone at the facility noticed the gaps in the records before a complaint forced inspectors through the door. Whether the night shift nurses who skipped the placement checks on February 6 and February 19 were following a pattern or making isolated errors.
Those questions have no answers in the inspection report.
What the report does confirm is that for ninety days, a resident who cannot eat on their own was receiving nutrition in amounts that sometimes bore no documented relationship to what a doctor had prescribed, and that on at least two nights, no one recorded checking whether the tube delivering that nutrition was even in the right place.
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.
Nobody caught it until a complaint triggered an inspection.
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.