Inspection Reports for
Crestview Nursing & Rehab
2401 South Des Moines Street, Webster City, IA, 505953099
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
55% worse than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
83% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 9, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, following acceptance of a credible allegation of substantial compliance.
Findings
The facility will be certified in compliance with health requirements effective November 20, 2025, based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction.
Inspection Report
Routine
Census: 58
Deficiencies: 5
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity during meal service, PASRR evaluations, care plan completeness, feeding tube care, and infection prevention practices.
Findings
The facility was found to have minimal harm deficiencies related to staff failing to treat residents with dignity during meal service, failure to submit timely PASRR evaluations, incomplete care plan reviews, failure to verify feeding tube placement before medication administration, and inadequate infection prevention practices by not wearing enhanced barrier precautions.
Deficiencies (5)
F 0550: The facility failed to treat residents with dignity during meal service by having staff stand over residents while assisting with eating instead of sitting next to them.
F 0644: The facility failed to submit required Level I and Level II PASRR evaluations to the state-designated authority prior to expiration for 2 residents.
F 0657: The facility failed to fully review and revise the comprehensive care plans for 2 residents to reflect current PASRR status and person-centered interventions.
F 0693: The facility failed to check placement of a jejunostomy feeding tube prior to administering medications and fluids for 1 resident.
F 0880: The facility failed to provide appropriate infection prevention practices by not wearing enhanced barrier precautions when providing care to a resident with a feeding tube and urinary catheter.
Report Facts
Residents reported in census: 58
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Interviewed regarding PASRR assessments and care plan revisions |
| Staff B | Registered Nurse | Observed administering medications without checking feeding tube placement and not wearing enhanced barrier precautions |
| Staff C | Certified Nursing Assistant | Observed assisting residents during meal service by standing over them |
| Staff D | Certified Nursing Assistant | Observed assisting residents during meal service by standing over them |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff behavior during meal service and infection prevention practices |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 5
Date: Nov 17, 2025
Visit Reason
The inspection was an annual recertification survey conducted from September 15, 2025, to November 17, 2025, to assess compliance with federal regulations for Crestview Nursing & Rehab.
Findings
The facility was found to have multiple deficiencies related to resident rights, PASARR coordination and assessments, care plan timing and revision, tube feeding management, and infection prevention and control. The facility failed to ensure residents were treated with dignity during meals, did not submit required PASARR evaluations timely, and did not follow proper infection control practices.
Deficiencies (5)
Failure to treat residents with respect and dignity during meal service, including inadequate assistance to residents with eating.
Failure to submit Level I and Level II PASARR evaluations timely for residents requiring them.
Failure to fully review and revise comprehensive care plans for sampled residents.
Failure to ensure proper tube feeding placement and monitoring for residents with feeding tubes.
Failure to follow enhanced barrier precautions and infection prevention practices for residents with indwelling feeding tubes and urinary catheters.
Report Facts
Census: 58
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Greenhut | Administrator | Signed the report and plan of correction |
| Staff C | Certified Nursing Assistant (CNA) | Observed during meal service assisting residents |
| Staff B | Registered Nurse (RN) | Observed administering medications and fluids via feeding tube |
| Staff A | Social Worker (SW) | Interviewed regarding PASARR assessments and care plans |
| Director of Nursing (DON) | Interviewed regarding infection control and staff expectations |
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
This document reports an onsite revisit inspection conducted on February 5, 2025, following a prior survey ending January 6, 2025, to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
Crestview Nursing & Rehab was found to be in compliance with the applicable federal requirements during this revisit inspection.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Date: Jan 6, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate pressure ulcer care and prevent new ulcers, and failure to ensure resident safety from accident hazards such as exposure to hot electric baseboard heaters.
Complaint Details
The complaint investigation was substantiated. Resident #1 suffered pressure ulcers that were not properly identified or treated, and burns from contact with a hot electric baseboard heater due to inadequate supervision and environmental safety measures. Immediate jeopardy was identified and removed after corrective actions. Resident #3 did not receive required physician face-to-face visits.
Findings
The facility failed to identify and properly treat pressure ulcers for Resident #1, resulting in actual harm. Additionally, the facility failed to prevent Resident #1 from coming into contact with a hot electric baseboard heater, causing burns to both legs and resulting in immediate jeopardy to resident health and safety. The facility took corrective actions to remove the immediate jeopardy. Another finding included failure to ensure a physician face-to-face visit for Resident #3 within required timeframes.
Deficiencies (3)
F0686: The facility failed to identify and treat pressure ulcers for Resident #1, resulting in actual harm with unhealed pressure injuries and inadequate documentation and care.
F0689: The facility failed to ensure Resident #1 was protected from accident hazards, resulting in immediate jeopardy due to burns from contact with an unprotected electric baseboard heater.
F0712: The facility failed to ensure Resident #3 received required face-to-face physician visits every 60 days, resulting in minimal harm or potential for actual harm.
Report Facts
Resident census: 60
Electric baseboard heater surface temperature: 124
Electric baseboard heater surface temperature: 130
Burn measurements: 17
Burn measurements: 5
Burn measurements: 0.1
Burn measurements: 3
Burn measurements: 1.7
Burn measurements: 0.1
Boundary board width: 7.5
Boundary board distance from heater: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Reported finding Resident #1 with legs on heater and described care and documentation |
| Staff B | Certified Nursing Assistant | Found Resident #1 on heater and assisted repositioning |
| Nurse Manager | Licensed Practical Nurse | Reported on treatment and room rearrangement for Resident #1 |
| Director of Nursing | Director of Nursing | Verified missed physician visit for Resident #3 and reported corrective actions |
| Director of Maintenance | Maintenance Director | Reported on heating system and temperature ranges of electric baseboard heaters |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective November 12, 2024.
Findings
The facility was found to be in substantial compliance with health requirements based on the accepted Plan of Correction; no specific deficiencies are detailed in this document.
Inspection Report
Routine
Census: 59
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration and resident safety, including accident prevention and proper use of safety equipment.
Findings
The facility failed to follow professional standards for medication administration for 3 of 7 residents observed, including improper insulin injection technique and failure to perform hand hygiene. Additionally, the facility failed to ensure safety for a resident who fell from a shower chair due to not being secured with a seat belt.
Deficiencies (2)
F 0658: The facility failed to follow professional standards for medication administration for 3 of 7 residents, including improper insulin pen use and failure to perform hand hygiene between residents.
F 0689: The facility failed to ensure a resident's safety by not securing the resident with a seat belt in the shower chair, resulting in a fall and minor injury.
Report Facts
Residents observed for medication administration: 7
Residents affected: 3
Resident census: 59
Resident fall incident date: 1
Insulin units administered: 5
Raised area size: 2
Red area size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in medication administration deficiencies for improper insulin injection and hand hygiene |
| Staff C | Registered Nurse (RN) | Responded to resident fall and conducted neurological assessments |
| Staff A | Certified Nurse Assistant (CNA) | Involved in resident fall incident for not securing seat belt |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication administration and resident safety expectations |
| Nurse Practitioner (NP) | Nurse Practitioner | Documented resident fall assessment and education |
| Staff E | Certified Nurse Aide (CNA) | Reported on resident's refusal to wear seat belt during spa bath |
| Staff F | Licensed Practical Nurse (LPN) | Reported on spa bath procedures and seat belt use |
| Staff G | Registered Nurse (RN) | Reported on spa bath procedures and seat belt use |
Inspection Report
Renewal
Census: 59
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as a recertification survey for Crestview Nursing & Rehab from October 21, 2024 to October 24, 2024 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with professional standards of quality related to comprehensive care plans and medication administration, and failed to ensure resident safety regarding accident hazards and supervision. Specific deficiencies involved insulin pen administration errors and failure to secure a resident in a shower chair, resulting in a fall.
Deficiencies (2)
Services Provided Meet Professional Standards - Facility failed to follow professional standards for medication administration for 3 of 7 residents observed, including insulin pen administration errors.
Free of Accident Hazards/Supervision/Devices - Facility failed to ensure resident safety for 1 of 3 residents reviewed for accidents; resident fell from shower chair due to failure to secure seat belt.
Report Facts
Total census: 59
Insulin units administered: 5
Brief Interview for Mental Status (BIMS) score: 15
Fall incident date: Jul 11, 2024
Plan of Correction date: Nov 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Observed administering insulin and medication errors related to insulin pen use |
| Staff C | Registered Nurse (RN) | Documented incident of resident fall and conducted neurological checks |
| Staff A | Certified Nurse Assistant (CNA) | Involved in resident fall incident and seat belt non-use |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff knowledge and resident safety expectations |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed about bathing procedures and seat belt use |
| Staff G | Registered Nurse (RN) | Interviewed about bathing procedures and seat belt use |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
An on-site revisit was conducted from 10/10/23 through 10/11/23 for the recertification survey ending August 29, 2023.
Findings
All deficiencies from the previous survey were corrected. The facility is in substantial compliance.
Inspection Report
Routine
Census: 58
Deficiencies: 9
Date: Aug 29, 2023
Visit Reason
Routine state inspection of Crestview Nursing & Rehab to assess compliance with regulatory requirements including resident care, medication administration, dietary services, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to submit required Level 2 PASRR evaluations, incomplete medication documentation, unlocked medication carts, unqualified dietary management staff, incorrect diet orders and servings, undated and unlabeled food items, and improper infection control practices during medication administration.
Deficiencies (9)
F0644: The facility failed to submit a Level 2 PASRR evaluation for 1 of 1 residents reviewed with mental health diagnoses.
F0695: The facility failed to document administration of prescribed respiratory medication for 1 of 1 residents reviewed.
F0761: The medication cart was found unlocked on 4 occasions when unattended, risking medication security.
F0801: The facility failed to employ a qualified Director of Food and Nutrition Services as required.
F0803: The facility failed to ensure residents received the correct portion size of meatloaf as per dietitian-approved menu.
F0805: The facility served incorrect diets to 2 residents and lacked diet orders for 4 residents, resulting in immediate jeopardy to resident health.
F0808: The facility failed to obtain physician diet orders upon admission for 4 residents and lacked a policy for diet order communication.
F0812: The facility failed to date, label, and cover open food items in the kitchen, risking food contamination.
F0880: The facility failed to follow infection control practices during medication administration for 2 residents, risking contamination.
Report Facts
Residents affected: 1
Residents affected: 1
Medication cart unlocked occasions: 4
Residents affected: 2
Residents affected: 4
Residents affected: 2
Facility census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Services | Named in failure to submit Level 2 PASRR evaluation |
| Staff E | Registered Nurse (RN) | Acknowledged failure to document respiratory medication administration |
| Staff B | Certified Medication Aide (CMA) | Acknowledged medication cart unlocked and improper handling of medication |
| Staff C | Certified Medication Aide (CMA) | Acknowledged medication cart unlocked and improper handling of medication |
| Dietary Manager | Acknowledged lack of qualifications and issues with diet orders and food portioning | |
| Administrator | Acknowledged dietary and medication administration deficiencies | |
| Assistant Director of Nursing (ADON) | Discussed diet order issues and communication | |
| Speech Therapist | Observed resident meal consumption and made diet recommendations | |
| Staff B | Certified Medication Aide (CMA) | Improper infection control handling of inhaler spacer and shoes |
| Staff C | Certified Medication Aide (CMA) | Improper handling of fish oil capsules during medication administration |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 9
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 21, 2023 to August 29, 2023.
Findings
The facility was found deficient in multiple areas including coordination of PASARR assessments, respiratory/tracheostomy care, medication administration, drug and biological labeling and storage, qualified dietary staffing, menu adequacy, food service, infection control, and therapeutic diet orders. Several residents' records and care plans were reviewed revealing failures in documentation, policy adherence, and staff qualifications.
Deficiencies (9)
Failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed for a Level 2 PASRR evaluation (Resident #37).
Failed to document the administration of a prescribed medication for 1 of 1 residents reviewed for Respiratory Care (Resident #50).
Medication cart was found unlocked and unoccupied on multiple occasions when the Certified Medication Aide responsible was not present.
Failed to have a qualified/certified dietary manager in place to supervise the kitchen.
Failed to ensure each resident received the 3 ounces of meatloaf per the menu approved by the facility's dietitian.
Failed to serve the correct diets to 2 out of 59 residents and failed to have diet orders for 6 residents on the Diet Type Report.
Failed to obtain physician diet orders for 4 out of 6 residents reviewed.
Failed to label and date all food items when opened in the kitchen.
Failed to establish and maintain an infection prevention and control program including proper medication handling and hand hygiene.
Report Facts
Census: 58
Deficiencies cited: 9
Residents without diet orders: 6
Residents without physician diet orders: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Gumpel | Administrator | Signed the initial comments and plan of correction. |
| Staff D | Social Services | Interviewed regarding PASRR evaluation and facility policy. |
| Staff E | Registered Nurse (RN) | Interviewed regarding medication administration and medication cart locking. |
| Staff F | Cook | Observed during lunch service and meal preparation. |
| Dietary Manager | Interviewed regarding qualifications and diet order management. | |
| Administrator | Confirmed dietary manager qualifications and policies. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding diet orders and medication orders. | |
| Speech Therapist | Observed meal consumption and made diet recommendations. | |
| Staff B | Certified Medication Aide (CMA) | Responsible for medication cart and medication administration. |
| Staff C | Certified Medication Aide (CMA) | Responsible for medication cart and medication administration. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Crestview Nursing & Rehab.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of facility reported incidents #111338-I and #109248-I was conducted by the Department of Inspection and Appeals from 4/19/2023 to 4/24/2023.
Findings
The facility was found to be in substantial compliance and in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 13, 2022
Visit Reason
The document is a plan of correction submitted following a previous inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective July 7, 2022, based on acceptance of the plan of correction. No specific deficiencies or findings are detailed in this document.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 2
Date: Jun 20, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 20 to June 22, 2022.
Findings
The facility was found deficient in ensuring appropriate medical justification for continued use of indwelling urinary catheters for residents and in properly disposing of garbage and refuse, including maintaining dumpster lids. These deficiencies posed risks related to infection control and pest attraction.
Deficiencies (2)
Failure to ensure clinical records documented medical justification for continued use of indwelling urinary catheters for a resident.
Failure to properly dispose of garbage and refuse, evidenced by an overflowing dumpster with trash and debris scattered on the ground.
Report Facts
Census: 46
Correction date: Correction date set for July 7, 2022.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A COVID-19 Focused Infection Control (FIC) survey and investigation of Complaint #100366-C and #100664-C was conducted from 12/27/2021 to 01/05/2022.
Complaint Details
Complaint #100366 - Not substantiated. Complaint #100664 - Not substantiated.
Findings
The investigation resulted in no deficiencies. Both complaints #100366 and #100664 were not substantiated.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Date: Mar 4, 2021
Visit Reason
The annual health survey was conducted from March 1 to March 4, 2021, to assess compliance with federal regulations related to infection prevention and control.
Findings
The facility failed to utilize proper infection control measures during medication administration for one resident and failed to perform hand hygiene between assisting residents in the dining room. Observations and interviews confirmed lapses in hand hygiene and infection control practices.
Deficiencies (1)
Failure to utilize infection control measures for 1 of 7 residents during medication administration and failure to perform hand hygiene between assisting residents in the dining room.
Report Facts
Census: 36
Medication administration observations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Named in infection control deficiency related to medication administration |
| Staff B | Certified Nurse Aide (CNA) | Named in hand hygiene deficiency during resident assistance |
| Stacy Leepheart | Administrator | Signed initial comments on the inspection report |
| Nurse Manager | Provided expectations regarding storage of inhaler and hand hygiene | |
| Director of Nursing | Provided expectations regarding hand hygiene between residents |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 1
Date: Nov 19, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted by the Iowa Department of Inspections and Appeals ending on 11/19/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found not to be in compliance with infection prevention and control practices, specifically failing to utilize appropriate infection control practices during resident care for 1 of 3 residents reviewed. Observations revealed improper hand hygiene and glove use by staff during perineal care.
Deficiencies (1)
Failure to utilize appropriate infection control practices during resident care, including improper hand hygiene and glove use by staff during perineal care for Resident #5.
Report Facts
Total residents: 45
BIMS score: 13
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed performing perineal care with improper infection control practices |
| Administrator | Interviewed regarding infection control practices and deficiencies |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Sep 17, 2020
Visit Reason
An investigation of complaints #87939-C, #89354-C, #89357-C and Facility Reported Incident #92418-1 ending on 9/17/20 was conducted, including a focused COVID-19 infection survey and complaint investigation.
Complaint Details
Complaint #87939-C was not substantiated. Complaint #89354-C was not substantiated. Complaint #89357-C was not substantiated. Facility Reported Incident #92418-1 was substantiated.
Findings
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #8, who had a history of falls and was on blood thinners. The resident sustained multiple falls resulting in a fractured forearm, subdural hematoma, and death. The facility did not follow interventions or increase supervision, and care plans lacked toileting and transfer assistance interventions.
Deficiencies (1)
Failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #8 with a history of falls and anticoagulant use, resulting in multiple falls and injuries.
Report Facts
Resident census: 48
Fall incident dates: 2
Fall assessment score: 10
BIMS score: 3
Fracture size: 1
Bruise size: 12
Subdural hematoma size: 11
Midline shift: 3.9
Date of death: Aug 12, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Worked with resident during falls, conducted neuro checks, and provided care |
| Staff C | Physical Therapy Assistant | Worked with resident prior to fall on 7/7/20 and witnessed fall incident |
| Staff E | Registered Nurse | Provided care and assisted resident after 7/16/20 fall |
| Staff B | Certified Nurse Aide | Provided care and observed resident behavior related to falls |
| Staff D | Certified Medication Aid | Provided care after 7/16/20 fall and assisted with transfers |
| Staff F | Certified Nurse Aide | Provided care and assisted resident with call button use |
| Staff G | Certified Medication Aid | Provided care and observed resident self-transferring without call button use |
| Director of Nursing | Director of Nursing | Provided information on resident care plans and supervision policies |
| Administrator | Facility Administrator | Provided information on quarantine policies and facility response |
Inspection Report
Abbreviated Survey
Census: 49
Deficiencies: 1
Date: Jun 17, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted to assess the facility's infection prevention and control program compliance.
Findings
The facility failed to utilize proper infection control techniques for three residents, including improper cleansing during incontinence care, inadequate cleaning of medical equipment, failure to disinfect mechanical lifts, and staff not performing hand hygiene after touching face masks.
Deficiencies (1)
Failure to utilize proper infection control techniques for three residents, including improper cleansing during incontinence care and inadequate hand hygiene.
Report Facts
Resident census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Observed assisting Resident #1 with toileting and infection control |
| Staff E | Certified Medication Aide (CMA) | Observed assisting Resident #1 and #3 with toileting and infection control, and touching face mask without hand hygiene |
| Staff F | Registered Nurse (RN) | Observed cleaning medical equipment improperly and assessing Resident #2 |
| Staff C | Certified Medication Aide (CMA) | Observed assisting Resident #3 with toileting and infection control |
| Staff D | Certified Nurse Aide (CNA) | Observed assisting Resident #3 with toileting and infection control |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed regarding cleaning of mechanical lifts and hand hygiene expectations |
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