Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestview Health & Rehab Ctr during CMS and state inspections, most recent first.
Multiple residents with varying levels of cognitive impairment experienced sexual and physical abuse or inappropriate contact by other residents and by a CNA, including alleged sexual touching, an observed oral sex act, a resident slapping another resident, unwanted touching in a resident’s room, breast pinching, and a resident being forcibly moved and striking his head on a doorframe. Although some events were documented in progress notes and one resident was sent to the hospital, the facility did not complete thorough investigations, did not promptly perform or document physical and psychosocial assessments, and did not revise care plans or implement clear protective interventions and monitoring to prevent further abuse, contrary to its own abuse prevention policy.
The facility failed to conduct thorough investigations into multiple allegations of physical and sexual abuse involving several residents with cognitive impairment, psychiatric conditions, and complex medical histories. In numerous cases, police were notified and case numbers obtained, but there was no follow-up with law enforcement, no or limited interviews with other residents or staff who might have witnessed or known about the incidents, and no timely physical or psychosocial assessments of the involved residents. This pattern included resident-to-resident physical altercations, alleged sexual contact between residents, and an allegation that a CNA forcefully moved a resident, causing a head injury, as well as a complaint that an LPN attempted to force medication and struck a resident with a remote. The Manager of Quality/Risk and the Administrator acknowledged that investigations were incomplete and did not meet the facility’s own abuse policy requirements for identifying and interviewing all involved persons and thoroughly documenting investigations.
Administration failed to implement abuse policies and procedures and did not ensure thorough investigations after multiple residents reported physical and sexual abuse by staff and other residents. Incidents included a resident being grabbed and thrown against a doorframe by staff, resulting in a laceration, several residents reporting inappropriate touching or sexual abuse by other residents, and one resident slapping another in the face without provocation. The Administrator and DON acknowledged that the facility lacked policies and procedures to guide staff in identifying, reporting, investigating, and preventing abuse, despite the Administrator’s responsibility to assure care that promotes quality, safety, and respect.
Surveyors found that the facility did not properly obtain or document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral disturbances was receiving Depakote ER for mood and agitation without any signed consent or documented risks vs benefits. A second cognitively intact resident with multiple psychiatric diagnoses was on four psychoactive medications (Klonopin, Abilify, Sertraline, Quetiapine); although a consent form was signed and witnessed due to the resident’s physical limitations, the form lacked required details such as specific drugs, dosages, frequencies, targeted behaviors, and potential side effects. A third severely cognitively impaired resident with dementia and other psychiatric conditions was receiving Valproate Sodium for behaviors without any signed consent or documented discussion of risks and benefits. The DON acknowledged that consents for these residents could not be located, despite a facility policy requiring such information and documentation before initiating or increasing psychotropic medications.
A resident with quadriplegia and idiopathic hypotension, who was cognitively intact, requested assistance in obtaining a Social Security card and a Georgia ID. Social services documented attempts to complete Social Security forms and discussed the issue with the resident’s out-of-state representative, who had health issues and relied on facility staff for help. An application for a Social Security card was completed, but there was no documented follow-up for more than three and a half months, and the resident never received the card or ID. During interviews, the resident and representative confirmed the documents were never obtained and described the situation as very stressful, while social services staff acknowledged that no follow-up occurred and that assisting with such matters was their responsibility under facility policy.
The facility did not ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any person.
The facility failed to protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and financial resources.
Failure to Provide Required Discharge Notice: The facility did not provide a written 30-day transfer or discharge notice to three residents before discharge, despite policy requiring notice generally at least 30 days in advance. One resident was discharged after a fall and hospital return, with family stating no notice was given and the MSW confirming the facility only gave verbal notice from admission. Two other residents, both with BIMS scores of 15, were also discharged without written 30-day notice; one had multiple neurological and psychiatric diagnoses, and another had limited resources and stated a desire for LTC. Staff stated the facility did not give 30-day notices to discharging residents.
Surveyors found that a resident did not receive an accurate assessment, as required, due to incomplete or inaccurate documentation of their condition or needs.
A facility failed to provide required one-to-one supervision for four residents with severe cognitive impairments, as outlined in their care plans. This neglect was identified through observations and interviews, revealing that night shift CNAs were not informed of the supervision requirements and were assigned additional residents, compromising care. One resident was found on the floor and sent to the hospital, highlighting the facility's failure to adhere to its policy on abuse, neglect, and exploitation.
Failure to Protect Residents From Abuse and Implement Protective Interventions After Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to implement adequate actions and care plan interventions after abuse allegations. One cognitively intact male resident with a history of verbal and sexual aggression toward staff was care planned for potential sexually abusive behavior, but his care plan and record contained no specific behavioral monitoring or interventions after two separate sexual abuse allegations by two cognitively intact female residents. One of these residents reported that he rubbed her inner thigh and hair in a way that made her feel violated, and documentation showed he was moved to another unit due to her allegation, yet there was no evidence of immediate physical or psychosocial assessment of her after the incident. The other resident reported being raped by this same male resident, was sent to the hospital, and refused examination, but her care plan did not show ongoing interventions to prevent further abuse by him. Another incident involved a male resident allegedly performing oral sex on his cognitively intact male roommate. A CNA discovered the roommate in bed with his penis exposed and the other resident bent over him, moving in an up‑and‑down motion. Progress notes documented that the social worker spoke with both residents three days later, but there was no evidence of an immediate physical assessment or timely psychosocial assessment of either resident to rule out physical or psychosocial harm. The care plans for both residents lacked any problem or interventions related to this sexual incident or measures to prevent further sexual abuse. Observations later showed the alleged perpetrator alone in a private room, rarely leaving his room and requiring extensive assistance, but there was no documentation of specific monitoring or protections related to the prior allegation. The facility also failed to adequately address physical abuse and inappropriate contact among other residents and by staff. One severely cognitively impaired resident with known behavioral issues had previously been placed on 1:1 care after attempting to hit staff and then hitting another resident, yet her care plan did not address a later incident in which she slapped another cognitively impaired resident in the face when redirected from striking staff. Although a progress note documented that no injuries were noted and the situation was de‑escalated, the investigation file was incomplete. In separate cases, a moderately impaired resident reported through a family member that another severely impaired resident entered her room and touched her body, and a cognitively intact resident was observed being pinched on the breast by another cognitively impaired resident, causing her to yell out. The investigative files confirmed these reports but did not show that care plans were updated or that protective measures were implemented. In addition, a severely cognitively impaired resident with Alzheimer’s disease sustained a head laceration when a CNA, while providing personal care with another aide present, grabbed the resident by the sweater, jerked him from a seated position, and swung him toward the bathroom after he refused care, causing his head to hit the doorframe. A nurse entered the room and witnessed the CNA swinging the resident and the impact with the doorframe. The facility’s Manager of Quality/Risk Manager, who conducted most abuse investigations, confirmed that the facility’s investigative materials for all of these incidents were incomplete and that abuse was substantiated only in the case of the physical abuse by one resident against another. She and the Administrator acknowledged there was no documentation of prompt resident assessments, care plan updates, or adequate measures to prevent further abuse by the involved residents and the CNA, despite facility policies requiring immediate protection, examination, psychosocial assessment, room or staffing changes, emotional support, and care plan revision after incidents of abuse.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of abuse, including physical and sexual abuse, involving numerous residents. For several incidents, the facility notified local law enforcement and obtained case numbers but did not follow up with the police department to obtain information about their investigations. In the cases involving a resident with a history of stroke who alleged being punched by another resident, later alleged sexual touching by a male resident, and was involved in a separate altercation with another resident who threw items at her, the facility’s investigative files lacked follow-up with police, interviews with other residents who may have witnessed or had knowledge of the events, and timely physical and psychosocial assessments of the involved residents. Similar investigative gaps were identified in an incident where a resident with an above-knee amputation was alleged to have hit another resident. The facility also failed to complete thorough investigations into serious allegations of sexual abuse between residents with significant psychiatric and cognitive diagnoses. In one incident, a CNA reported finding one resident bent over another resident’s bed with his penis in the other resident’s mouth; both residents had diagnoses including paranoid schizophrenia and vascular dementia. Although police were notified and a case number was obtained, the facility did not follow up with law enforcement, did not interview other residents who may have been exposed to or had knowledge of the incident, and did not complete timely physical or psychosocial assessments of either resident. In another case, a cognitively impaired resident reported being touched on the thigh by another resident with severe cognitive impairment while in bed; both residents later denied or could not recall the event, and the facility did not obtain statements from other potentially affected residents or staff who may have been present, determining the allegation unsubstantiated based solely on the residents’ lack of recall. Additional deficiencies in abuse investigations were identified in incidents of resident-to-resident physical abuse and alleged staff-to-resident abuse. In one case, a cognitively intact resident reported that another resident with dementia pinched her breast; while the facility determined that abuse occurred and documented some interviews, it did not obtain statements from other residents potentially affected or staff who may have been present. In another incident, a resident with Alzheimer’s disease and severe cognitive impairment sustained a head laceration when a nurse aide allegedly grabbed the resident by the sweater and shirt, jerked the resident from a seated position, and swung the resident toward the bathroom, causing the resident’s head to hit the doorframe; despite witness statements from another aide and an LPN, the facility ultimately determined it could not verify abuse after the resident later denied being abused. In a separate complaint from a resident with severe cognitive impairment and significant behavioral disturbances, who alleged that an LPN tried to force a pill down his throat and hit him with a TV remote, the facility’s investigation included multiple documents and interviews but did not include interviews of other residents cared for by the implicated LPN. The pattern of incomplete investigations extended to additional resident-to-resident physical abuse incidents. In one event, a resident with vascular dementia and a history of breast cancer attempted to hit a nurse and then slapped another resident with dementia and diabetes in the face; the facility notified responsible parties and updated care plans but did not document interviews with other residents in the area or psychosocial assessments of the involved residents, despite notifying police and receiving a case number. Across these events, the Manager of Quality/Risk Manager, who conducted most of the abuse investigations, confirmed that investigation information was never obtained from the local police department, that timely physical and psychosocial assessments were not completed, and that residents who may have been present or had knowledge of the incidents were not interviewed. The Administrator, who served as the Abuse Coordinator and reviewed investigations, acknowledged that the referenced investigations were not complete, even though facility policy required identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.
Failure to Implement Abuse Policies and Investigate Multiple Abuse Allegations
Penalty
Summary
Facility administration failed to implement its abuse policies and procedures for 15 of 25 sampled residents, resulting in noncompliance that surveyors determined had caused or had the likelihood to cause serious injury, harm, impairment, or death. The Administrator did not ensure residents remained free from neglect and abuse after multiple allegations of physical, sexual, and other forms of abuse were made by and between residents and staff. Specific incidents included a resident alleging that a staff member grabbed him by the shirt and threw him against a doorframe, causing a laceration above his eye, and several residents reporting that other residents touched them inappropriately in their private areas or engaged in sexual abuse. Another incident involved a resident slapping another resident in the face without provocation. In each of these situations, the administration failed to ensure adequate actions were taken to prevent further potential abuse by staff or residents. The Administrator also failed to ensure thorough investigations of abuse allegations for 14 residents reviewed for abuse. Despite multiple reports and observations of alleged abuse, including sexual abuse between residents, physical abuse by staff toward a resident, and physical abuse between residents, the facility did not conduct comprehensive investigations as required. During an interview, the Administrator and DON confirmed that the facility lacked policies and procedures directing staff on how to identify, report, investigate, and prevent resident abuse, despite the Administrator’s job description assigning responsibility for assuring that care promotes quality, safety, and respect. Surveyors identified Immediate Jeopardy beginning when one resident alleged that another resident sexually abused her by touching her between her legs, and found that the facility’s failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of psychotropic medications related to informed consent and documentation of risks and benefits for three residents. For one resident with dementia with behavioral disturbances and adjustment disorder, the EMR showed an order for Depakote ER 250 mg at bedtime for mood stabilization and episodic agitation, but there was no signed consent or documentation of risks versus benefits for psychoactive medications in the resident’s miscellaneous documents. Another resident with schizoaffective disorder, bipolar type, bipolar disorder, adjustment disorder with mixed anxiety and depression, and psychosis had intact cognition and was receiving multiple psychoactive medications, including Klonopin, Abilify, Sertraline, and Quetiapine. The consent form for psychoactive medication for this resident was signed and witnessed by facility social workers because the resident had no hands or arms and verbally gave permission, but the form did not list any of the required medication details such as drug name, dosage, frequency, targeted behavior, or potential side effects for any of the four medications. A third resident with dementia with behavioral disturbances, personality disorder, major depressive disorder, and psychosis, and who was severely cognitively impaired with a BIMS score of 0, had a physician order for Valproate Sodium oral solution 250 mg/5 ml, 2.5 ml twice daily for behaviors. Review of this resident’s miscellaneous documents also showed no signed consent or documentation of risks versus benefits for psychoactive medications. During an interview, the DON confirmed she was unable to locate signed psychoactive medication consents for these three residents. The facility’s own policy on the use of psychotropic medications, revised in May 2025, requires that prior to initiating or increasing psychotropic medications, the resident, family, and/or representative be informed of benefits, risks, alternatives, and any black box warnings, and that this information be documented in a format such as a written consent form or narrative note, which was not done in these cases.
Failure to Provide Social Services Assistance for Resident Identification Documents
Penalty
Summary
The facility failed to provide medically-related social services to assist a cognitively intact resident in obtaining a Social Security card and state identification, as required by facility policy. The resident, who had quadriplegia and idiopathic hypotension, was admitted to the facility and had a BIMS score of 15/15, indicating intact cognition. Care planning notes documented that during an interdisciplinary care plan meeting with the resident’s mother/representative, the SW informed her that another attempt had been made to complete the Social Security form so the resident could receive a Social Security card, with the resident’s stated end goal being to obtain a Georgia ID. At a subsequent care plan meeting, the SW discussed with the mother whether she could assist with getting the Social Security card after two unsuccessful attempts, and it was noted there were no psychosocial concerns at that time. An application for a Social Security card was completed for the resident on 11/10/2025, but a review of the comprehensive record showed no documentation of any follow-up by the facility after that date regarding the Social Security card or Georgia ID. In an interview, the resident confirmed he had never received his Social Security card or Georgia ID and stated he would like to obtain those items. The resident’s mother/representative confirmed the card had never been received, reported that the situation had been very stressful for both of them, and stated she lived out of state with her own health problems and was relying on facility staff for assistance. During interviews, the SW and SSD confirmed there had been no follow-up by the facility since 11/10/2025, a period of more than three and a half months, and acknowledged that social services staff were responsible for assisting with such matters. The facility’s Social Services Policy stated that the facility would provide medically-related social services to assist each resident in attaining or maintaining their highest practicable well-being, including making arrangements for obtaining personal items and making referrals to outside entities.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care.
Failure to Protect Residents' Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that each resident was safeguarded against unauthorized or improper use of their personal property or financial resources. Specific details about the actions or inactions that led to this deficiency, as well as information about the residents involved or their medical history, are not provided in the report excerpt.
Failure to Provide Required 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day written transfer or discharge notice to three sampled residents, R3, R6, and R7, or their representatives before discharge. The facility policy titled Transfer and Discharge (including AMA) stated that residents are generally to receive notice at least 30 days prior to a facility-initiated transfer or discharge, and that the notice must be provided in a language and manner the resident and representative can understand. For R3, the record showed admission with diagnoses including central cord syndrome at C4, burn injury, syncope and collapse, and adjustment disorder with mixed anxiety and depressed mood. R3’s MDS showed a BIMS score of 15, indicating no cognitive impairment. After a fall in the bathroom, R3 was sent to the ED, returned from the hospital the same day, and was then discharged from the facility to home. A family member stated the facility discharged R3 without notice, did not contact him, and did not provide a 30-day discharge notice. The MSW stated the facility did not give a 30-day discharge notice and only gave verbal notice starting from admission. The EMR contained no 30-day notice for R3 or the representative. For R6, the record showed diagnoses including encephalitis and encephalomyelitis, nontraumatic intracerebral hemorrhage, severe protein-calorie malnutrition, epilepsy, vascular dementia, schizoaffective disorder, schizophrenia, and bipolar disorder. R6’s MDS showed a BIMS score of 15. The EMR showed R6 was discharged with no written 30-day notice. For R7, the record showed diagnoses including severe protein-calorie malnutrition, polyneuropathy, alcohol abuse, foot drop, generalized muscle weakness, and mild cognitive impairment. R7’s MDS showed a BIMS score of 15. Social work documentation showed R7 stated he had no income, no family to live with, and wanted LTC due to lack of income and resources, yet the EMR showed he was not given a written 30-day notice prior to discharge. The MSW manager stated the facility identified discharge plans within the first 48 hours after admission and did not give 30-day notices to discharging residents.
Failure to Ensure Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete information being documented about their condition or needs. This lapse in the assessment process was observed by surveyors during their review of resident records and facility practices.
Neglect Due to Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to protect the rights of four residents from neglect, as they did not receive the required one-to-one supervision and monitoring as outlined in their care plans. This deficiency was identified through observations, staff interviews, and record reviews. Specifically, one resident was found on the floor and sent to the hospital for evaluation, although they were discharged without injury. The care plans for these residents indicated severe cognitive impairments and required constant supervision, which was not provided during the night shifts. The facility's policy on abuse, neglect, and exploitation mandates increased supervision for residents requiring one-on-one care. However, the review of CNA assignments from April to July 2024 revealed that the necessary supervision was not implemented during night shifts. Interviews with the Assistant Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to follow care plans and physician orders for one-on-one supervision. The night shift CNA was assigned additional residents, which compromised the ability to provide the required supervision. The investigation into the incident revealed that the CNA assigned to the resident requiring one-on-one supervision was unaware of this requirement and was tasked with caring for 14 additional residents. The facility's failure to ensure that staff were informed and compliant with care plan interventions led to the neglect of the residents' needs. The facility's actions, including the suspension and termination of involved staff, were not part of the deficiency but were noted during the investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fulton Center For Rehabilitation Llc | 0.1 mi | ★★★★★ | 0 | 0 |
| Bonterra Transitional Care & Rehabilitation | 0.6 mi | ★★★★★ | 5 | 0 |
| Reliable Health & Rehab At Lakewood | 1.6 mi | ★★★★★ | 12 | 0 |
| Healthcare At College Park, Llc | 2.4 mi | ★★★★★ | 0 | 0 |
| A.g. Rhodes Home, Inc, The | 4.9 mi | ★★★★★ | 8 | 0 |
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