Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity During Meal Assistance: Two residents with severe cognitive impairment were observed during lunch service while CNAs stood over them and fed them by bringing food and drinks to their mouths. One resident's care plan called for setup assistance and the other was documented as independent with eating, yet staff repeatedly hovered over both residents during meal service. The DON stated staff were expected to sit next to residents while assisting with meals for dignity purposes, and the facility policy said staff should be seated, if possible, while feeding a resident.
PASRR evaluations were not submitted before the authorization periods expired for two residents. One resident with anxiety, depression, and bipolar disorder had a short-term PASRR approval that required re-screening, but the SW acknowledged the Level I PASRR was overdue. Another resident with severe cognitive impairment and diagnoses including anxiety and bipolar disorder had a short-term Level II PASRR that expired, and the record lacked a new submission before or after the end date.
Incomplete PASRR Care Plan Updates: Two residents had Care Plans that were not fully reviewed and revised to match current PASRR status and services. One resident’s Care Plan still listed outdated PASRR II references after the approval had expired, and another resident’s PASRR-related Care Plan lacked specific therapy details and had not been updated to reflect required psychiatric, rehab, and community placement supports.
A resident with intact cognition, quadriplegia, seizure disorder, and peripheral vascular disease received nutrition through a j-tube, and the care plan directed staff to check tube placement and residuals per order. A RN was observed administering meds and fluids via the j-tube without first verifying placement, and later acknowledged the omission; the DON stated staff were expected to follow the physician orders and check placement before giving fluids.
A RN failed to use EBP while performing j-tube site care for a resident with an external catheter, quadriplegia, seizure disorder, and PVD. The resident’s care plan called for EBP due to the j-tube and urinary catheter, and the DON stated staff were expected to wear EBP for residents with feeding tubes and catheters.
A resident with impaired cognition and mobility was burned by an electric baseboard heater in their room, which had a surface temperature of 124 degrees Fahrenheit. The resident, who required significant assistance for mobility, was found with their legs on the heater, resulting in burns. The facility's staff failed to ensure the resident's safety by not adequately monitoring the heater's temperature and not maintaining a safe distance between the bed and the heater.
A resident with severely impaired cognition and mobility assistance needs developed multiple pressure ulcers that were not identified or treated by the facility. Despite having a care plan for pressure ulcer prevention, the facility failed to document or address the resident's pressure wounds, which were later identified during a hospital assessment. The deficiency highlights a failure in the facility's processes for monitoring and managing pressure ulcers.
A resident with severely impaired cognition and multiple medical conditions was not seen by a Physician after a specified date, missing the required 60-day face-to-face visit. The DON confirmed the oversight during Physician rounds, despite the facility's policy mandating such visits.
An LPN failed to follow proper medication administration protocols, including incorrect insulin pen use and lack of hand hygiene between administering medications to two residents. The LPN admitted to not following training, and the DON confirmed awareness of the correct procedures.
A resident with a history of renal failure and other conditions fell from a shower chair due to not being secured with a seat belt, despite facility protocols requiring it. The resident was injured during a bathing procedure when a CNA failed to secure the belt, leading to a fall and head injury. Staff interviews revealed inconsistencies in the resident's refusal and staff actions, highlighting a lapse in safety protocols.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat two residents with dignity during meal service. Resident #6 had a BIMS score of 0, indicating severe cognitive impairment, and diagnoses including other orthopedic conditions, cirrhosis, renal insufficiency, and non-Alzheimer's dementia. The resident's care plan indicated a need for help with ADLs due to weakness and stated the resident could eat independently after setup. During lunch observations in the CCDI unit, a CNA stood over Resident #6 while assisting with eating and drinking, bringing bites of food on a fork and bringing the cup of fluid to the resident's mouth instead of sitting next to the resident. This same type of assistance was observed again on a later lunch observation, with the CNA continuing to stand over the resident while feeding her. Resident #18 also had a BIMS score of 0 and diagnoses of hyperlipidemia and non-Alzheimer's dementia. The resident's care plan identified a need for help with ADLs due to dementia and directed staff to provide setup assistance for eating, while documenting the resident as independent with eating. During lunch observations in the CCDI unit, CNAs stood over Resident #18 while assisting with meals, placing food on a fork and bringing it to the resident's mouth and bringing a drink to the resident's mouth. This was observed on multiple occasions, including one observation where the CNA remained standing over the resident throughout the meal assistance. The DON stated staff were expected to sit next to residents while assisting with meals and not hover over them for dignity purposes, and the facility policy stated staff should be seated, if possible, while feeding a resident.
PASRR evaluations not submitted before authorization expired
Penalty
Summary
The facility failed to submit required Level I and Level II PASRR evaluations to the appropriate state-designated authority before the expiration of the authorized timeframes for two residents. One resident had diagnoses of anxiety disorder, depression, and bipolar disorder, and the PASRR on record authorized short-term nursing facility services for 60 days with a requirement for re-screening by or before the 60th day if the resident remained in the facility beyond that period. Staff interviews showed the Social Worker understood PASRRs were usually completed by the hospital before admission and that she tracked due dates through the authorized PASRR company, but she acknowledged this resident was overdue and that the new Level I PASRR had not yet been completed. The second resident had a BIMS score of 7 indicating severe cognitive impairment, diagnoses including medically complex conditions, anxiety disorder, and bipolar disorder, and use of antipsychotic and antianxiety medications during the look-back period. The resident’s care plan noted a short-term PASRR approval that had expired, and the record contained a prior short-term Level II PASRR approval with a time-limited end date. However, the record lacked a new Level II PASRR submission before or after the approval ended. During interview, Staff A confirmed the last Level II PASRR had expired and acknowledged another PASRR had not been completed since November 2023 and should have been submitted by the expiration date.
Incomplete PASRR Care Plan Updates
Penalty
Summary
The facility failed to fully review and revise the comprehensive Care Plan for 2 of 16 residents sampled for Care Plan review. For one resident, a PASRR completed for short-term nursing facility services authorized convalescent care for 60 days and required re-screening by the 60th day if the resident remained in the facility beyond the approved timeframe. The resident’s Care Plan, initiated after admission, still referenced PASRR level II three times, including goals and interventions, even though Staff A, SW later stated those references had been cancelled and should not have remained on the current Care Plan. Staff A also stated the resident was a short-term PASRR that had been missed and was due for another screening. For the second resident, the MDS documented severe cognitive impairment with a BIMS score of 7 and diagnoses including medically complex conditions, anxiety disorder, and bipolar disorder. The facility’s submitted Level II PASRR identified the resident as meeting criteria for serious mental illness and required specialized services including ongoing psychiatric medication management, individual therapy by a licensed behavioral health professional, rehabilitative services, and community placement supports. Although the Care Plan included a PASRR focus area, the interventions/tasks section did not list the therapist’s name or therapy frequency, and the Care Plan still documented the short-term PASRR approval as expired while not being updated since 2023 to reflect the PASRR recommendations or revised to be person-centered. Staff A acknowledged the template had not been updated with specific interventions for this resident and that the Care Plan was not updated, revised, or comprehensive as expected.
Failure to Verify J-Tube Placement Before Administration
Penalty
Summary
The facility failed to check placement of a jejunostomy tube before administering medications and fluids for one resident. The resident had a BIMS score of 13 indicating intact cognition and diagnoses including quadriplegia, seizure disorder, and peripheral vascular disease. The MDS documented that the resident received nutrition through a jejunostomy feeding tube, and the care plan directed staff to check tube placement and gastric contents/residual volume per order. On 9/17/25, a RN was observed administering medications and fluids via the j-tube without checking placement first. During interview, the RN acknowledged she did not check placement prior to administering the fluids and stated the nurse would check placement by pulling back stomach contents. The facility policy on verifying feeding tube placement stated placement should be verified before beginning a feeding, flushing the tube, or administering medications via feeding tube, and the DON stated staff were expected to follow physician orders and check placement prior to administering fluids.
Failure to Use Enhanced Barrier Precautions During J-Tube Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices by not following enhanced barrier precautions for one resident reviewed. The resident had a BIMS score of 13 indicating intact cognition, used an external catheter, and had diagnoses including quadriplegia, seizure disorder, and peripheral vascular disease. The resident also received nutrition through a jejunostomy feeding tube (j-tube). The care plan dated 7/25/25 instructed staff to wear enhanced barrier precautions due to the resident’s indwelling j-tube and urinary catheter. On 9/17/25 at 11:10 AM, a Registered Nurse was observed completing a treatment to the resident’s j-tube site and did not wear enhanced barrier precautions. During interview at 12:15 PM, the RN acknowledged she should have worn enhanced barrier precautions while doing the treatment. The facility policy on Enhanced Barrier Precautions, revised 5/8/24, identified device care such as feeding tubes and urinary catheters as high-contact activities requiring gowns and gloves, and the Director of Nursing stated staff were expected to wear enhanced barrier precautions for residents with feeding tubes and catheters.
Resident Burned by Electric Heater Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to ensure a safe environment for a resident who required significant assistance for mobility, resulting in the resident coming into contact with an electric baseboard heater. The resident, who had severely impaired cognition and required a mechanical lift for transfers, was found with their legs on the heater, leading to burns. The heater in the resident's room, as well as others in the facility, had surface temperatures ranging from 124 to 130 degrees Fahrenheit, which were considered unsafe for prolonged contact. The resident's medical history included non-Alzheimer's dementia, malnutrition, depression, arthritis, hyperlipidemia, and a recent urinary tract infection. The resident was also at risk for pressure ulcers and had existing skin integrity issues. On the night of the incident, the resident was found with their legs off the bed and in contact with the heater, resulting in multiple blisters and burns on both legs. The staff did not immediately notify the physician or the resident's family, and initial treatment was delayed. Interviews with staff revealed a lack of awareness about the heater's potential hazard and inadequate measures to prevent the resident from coming into contact with it. The facility had boundary boards in place to keep beds away from heaters, but these were not consistently effective. The staff's failure to recognize and mitigate the risk posed by the heater contributed to the resident's injuries.
Removal Plan
- Resident #1 immediately positioned away from heater
- Assessment and First aid initiated, primary care provider (PCP) and wife updated
- Resident #1's room rearranged with beds moved to wall without a register
- Bed placement audit performed for all resident beds with electric heaters and any beds with concern were moved to safe distance of 3 feet
- Safe touch surface audits done on all electric registers
- Room thermostats to be set no higher than 71-degree F unless management notified
- Random safe touch audits with surface touch thermometer to include every room in 100, 200 and 300 halls for the remainder of the season. The facility will follow the safe water temperature of 100 degrees per Appendix PP in the State Operations Manual.
- Facility will audit safe distance of beds from heater five times a week for 3 months and then quarterly, done by maintenance or assigned person
- All staff training for identifying and reporting hazards, bed positioning and thermostats. All staff assigned safety hazard in-service training videos to be completed immediately.
- Purchasing designee actively looking for a safe cover or similar mechanism, if one available
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify and provide appropriate treatment for pressure ulcers in a resident, leading to a deficiency in care. The resident, who had severely impaired cognition and required substantial assistance with mobility, was at risk for developing pressure ulcers. Despite this, the facility did not document or treat pressure ulcers on the resident's left heel, posterior left knee, and coccyx, which were later identified during a hospital assessment. The resident's care plan included interventions such as pressure-reducing devices, nutritional supplements, and regular repositioning to prevent pressure ulcers. However, the facility's records lacked documentation of the pressure wounds, and staff interviews revealed inconsistencies in the reporting and assessment of the resident's skin condition. The Nurse Manager admitted to not thoroughly examining the resident's skin during treatment, and the facility's policy on pressure injury prevention and management was not effectively implemented. Hospital records indicated that the resident had multiple pressure injuries, including a stage three pressure wound to the coccyx and unstageable pressure wounds to the left heel and posterior left knee. The Wound Center RN confirmed that these wounds could not have developed overnight, suggesting a lack of timely identification and intervention by the facility. The deficiency highlights a failure in the facility's processes for monitoring and managing pressure ulcers, resulting in inadequate care for the resident.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to ensure that a Physician or Non-Physician Practitioner (NPP) conducted a face-to-face visit with a comprehensive assessment for a resident every 60 days, as required. Specifically, Resident #3, who had a severely impaired cognition with a Brief Interview for Mental Status (BIMs) score of 3, was not seen by a Physician after October 15, 2024. The resident's medical history included hypertension, hyperlipidemia, other fracture, non-Alzheimer's dementia, cerebrovascular accident (CVA), and chronic lung disease. The Director of Nursing (DON) confirmed that the resident was missed during Physician rounds in December 2024, despite two different Physicians visiting the facility. The facility's policy required residents to be seen at least every 60 days by a Physician or delegate, which was not adhered to in this case.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards during medication administration for three residents, as observed by surveyors. Resident #27, who has intact cognition and a history of renal failure, diabetes, anemia, and orthostatic hypotension, was administered insulin by an LPN who did not follow the correct procedure. The LPN injected insulin into Resident #27's abdomen but failed to hold the insulin pen in place for the recommended duration before withdrawing it, contrary to the manufacturer's instructions. This oversight was acknowledged by the LPN, who admitted to not following the training received for insulin pen administration. Additionally, the LPN was observed administering medications to multiple residents without performing hand hygiene between each administration. The LPN set up medications for two residents simultaneously, which included unlabeled medication cups, and failed to perform hand hygiene before or after administering the medications. The Director of Nursing confirmed that the LPN was aware of the correct procedures and acknowledged the failure to adhere to them, including the immediate withdrawal of the insulin pen and the lack of hand hygiene.
Failure to Secure Resident in Shower Chair Leads to Fall
Penalty
Summary
The facility failed to ensure the safety of a resident during a bathing procedure, leading to an accident. A resident, who had a history of renal failure, diabetes, anemia, and orthostatic hypotension, required partial assistance with bathing. Despite having a care plan that highlighted the risk of falling due to weakness, the resident was not secured with a seat belt in the shower chair. During the process of lifting the chair, the resident began coughing, became pale, and fell from the chair, resulting in a head injury and a scuffed knee. Interviews and observations revealed discrepancies in staff actions and resident preferences. The resident reported that the staff forgot to secure the seat belt, while the staff claimed the resident refused it. The incident occurred when a CNA was assisting the resident, and the chair was lifted approximately one foot off the ground. The CNA admitted to not securing the seat belt and acknowledged receiving training afterward. Other staff members, including a CNA and nurses, confirmed that the use of a seat belt is mandatory and that they would not proceed with a bath if a resident refused the belt. The facility's equipment manual also emphasized the importance of securing the seat belt to prevent injury. Despite the resident's cognitive awareness and occasional refusal of the seat belt, the facility's policy and staff training required its use for safety. The incident highlighted a lapse in following established safety protocols, resulting in the resident's fall and subsequent injuries.
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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 Webster City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southfield Wellness Community | 0.5 mi | ★★★★★ | 24 | 0 |
| Rotary Senior Living | 14.6 mi | ★★★★★ | 3 | 1 |
| Stratford Specialty Care | 14.7 mi | ★★★★★ | 5 | 0 |
| Marian Home | 17.6 mi | ★★★★★ | 0 | 0 |
| Grandview Healthcare Center | 17.7 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.