Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crestwood Manor - Fremont during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, who was able to communicate clearly and had no behavioral issues, was physically struggled with by an RN attempting to enforce a fluid restriction. The RN grabbed the resident's arm to take away a cup of water, resulting in a scratch and emotional distress. Staff interviews and documentation confirmed the physical altercation, and facility leadership stated that staff are expected to use calm communication and avoid physical handling unless there is immediate danger.
Staff failed to keep the nourishment refrigerator at or below 41°F as required, with temperature logs showing repeated readings above this limit and no timely action taken. Food items in the refrigerator were also not consistently labeled or dated, and staff interviews revealed confusion about proper procedures and temperature standards. This deficiency impacted 64 residents on the affected hall.
A resident with a history of schizoaffective disorder and assaultive behavior became agitated when a CNA removed their juice, leading to the resident throwing juice at the CNA. The CNA retaliated by throwing juice back and threatening the resident with a disinfectant spray bottle, accompanied by a verbal threat. Multiple staff witnessed the incident, and documentation confirmed the CNA's actions, which violated facility policy prohibiting abuse.
A facility failed to follow its policy for abuse investigations after an incident where a CNA threw juice at a resident and gestured with a spray bottle. Although policy required interviewing other cognitively intact residents to check for a history of inappropriate staff behavior, only the involved resident was interviewed, and no additional resident interviews were conducted.
The facility did not report an allegation of theft involving a resident's property to the state survey agency and failed to submit a required investigation report after an abuse allegation involving a CNA and a resident. Staff interviews revealed that allegations were not always escalated or reported as required, resulting in incomplete and delayed notifications to authorities.
Failure to Maintain Resident Dignity During Fluid Restriction Enforcement
Penalty
Summary
A deficiency occurred when a registered nurse (RN) physically struggled with a resident to take away a cup of water, resulting in the resident feeling disrespected and sustaining a scratch on the arm. The resident, who had a diagnosis of schizoaffective disorder but was able to communicate clearly and had no history of behavioral symptoms directed toward others, reported that the RN grabbed his arm and scratched him while attempting to enforce a fluid restriction. The resident expressed feeling treated like a child and experienced emotional distress as a result of the incident. Multiple staff interviews confirmed that the RN attempted to take the cup of water from the resident, leading to a physical struggle. A certified nursing assistant (CNA) and another RN witnessed the event, with one staff member intervening to stop the struggle and clean up spilled water. The progress notes documented the resident's report of being scratched by the nurse during the incident, with visible evidence of a scab and red mark on the resident's forearm. The RN involved acknowledged attempting to take the cup from the resident and stated that she had received crisis prevention training. The facility's crisis prevention instructor clarified that staff are not permitted to physically handle residents unless there is a danger to self or others. The director of nursing (DON) stated that the expectation is for staff to communicate calmly with residents, explain risks, and avoid physical altercations.
Failure to Maintain Proper Refrigerator Temperatures and Food Labeling
Penalty
Summary
The facility failed to maintain the [NAME] Hall nourishment refrigerator at or below the required temperature of 41 degrees Fahrenheit, as documented by multiple temperature logs showing readings consistently above this threshold over a period of two months. Staff recorded temperatures ranging from 42 to 48 degrees Fahrenheit on numerous occasions, yet there was no evidence that appropriate action was taken to address these out-of-range temperatures. The facility's own policy required staff to notify the Food Nutrition Services Director, or in their absence, Maintenance and the Administrator, if temperatures were not within standards, but the Maintenance Supervisor confirmed he was not notified of the high temperatures until much later. Additionally, food items stored in the nourishment refrigerator were not consistently labeled or dated as required by facility policy. During an observation, an unlabeled and undated half-eaten carton of spaghetti was found in the refrigerator. Staff interviews revealed a lack of knowledge regarding the correct temperature standards and the procedures for labeling and dating food items. Some staff believed the acceptable temperature range was higher than the regulatory requirement, and there was confusion about who was responsible for monitoring and addressing temperature deviations. The Dietary Manager stated she did not monitor the nourishment refrigerators on the nursing units, and the Maintenance Supervisor only checked the refrigerator temperature monthly. The Administrator and Director of Nursing both stated their expectations that the refrigerator should be maintained at or below 41 degrees Fahrenheit and that all food items should be labeled and dated, but these expectations were not consistently met in practice. The deficiency affected 64 of the 111 residents residing on the [NAME] Hall.
Failure to Protect Resident from Staff-Perpetrated Abuse
Penalty
Summary
A deficiency occurred when a staff member failed to protect a resident from abuse during a confrontation in the dining room. The resident, who had a history of schizoaffective disorder, type 2 diabetes, and assaultive behavior, became agitated after a CNA removed a cup of juice from their meal tray. In response, the resident threw the juice at the CNA. Multiple staff statements and documentation confirm that the CNA then threw juice back at the resident and subsequently approached the resident with a disinfectant spray bottle, aiming it at the resident and making a threatening statement. The incident was witnessed by several staff members, including a registered nurse and a special treatment program counselor, who observed the CNA's actions and heard the threatening language directed at the resident. The resident was described as having intact cognition and did not sustain any injuries or changes in behavior following the incident. There was no evidence of a prior history of conflict between the CNA and the resident. Facility records, including progress notes, abuse report forms, and staff interviews, consistently documented that the CNA did not deny the actions and admitted to losing their temper. The facility's policy clearly prohibits any form of abuse, including physical or mental harm, and the actions of the CNA were in direct violation of this policy, resulting in a failure to protect the resident's right to be free from abuse.
Failure to Conduct Thorough Abuse Investigation per Facility Policy
Penalty
Summary
The facility failed to implement its policy requiring a thorough investigation following an incident of abuse involving a certified nursing assistant (CNA) and a resident with intact cognition and a history of assaultive behavior. The incident occurred when the CNA took a cup of juice from the resident, prompting the resident to throw the juice at the CNA. In response, the CNA threw juice back at the resident, gestured with a disinfectant spray bottle as if to spray the resident, and made a confrontational statement. The CNA did not deny the incident, and the event was reported to supervisory staff and documented in the resident's records. Despite facility policy specifying that other cognitively alert residents should be interviewed to determine if there was a history of inappropriate staff behavior, no such interviews were conducted. The administrator and assistant administrator confirmed that no additional resident interviews were completed, and the DON stated that only the involved resident was interviewed, as they believed no other residents were present during the incident. The investigation did not include interviews with other residents who may have had contact with the CNA, contrary to facility policy.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state survey agency for one resident and did not timely report an allegation of abuse or submit the results of the investigation for another resident. In the first case, a resident with schizoaffective disorder and intact cognition accused a social services staff member of stealing a $1,400 check upon admission. The allegation was documented in the resident's progress notes, but the social services staff did not report the claim to the Administrator, citing a lack of evidence that the resident had a check. The Administrator confirmed that no self-report was made to the state survey agency, as she believed there was no actual property missing. The Director of Nursing was also not notified of the allegation and stated that she would have expected staff to report such claims for investigation and subsequent reporting to the state agency. In the second case, another resident with schizoaffective disorder and type 2 diabetes, and with intact cognition, was involved in an incident where a CNA threw juice on the resident after the resident threw juice at the CNA. The CNA also gestured with a disinfectant spray bottle and made a confrontational statement to the resident. The incident was documented, and the CNA was suspended pending investigation. The facility notified the state survey agency of the abuse allegation, but there was no evidence that the required five-day investigation report was submitted. The Assistant Administrator, who investigated the incident, could not recall if the final report was sent to the state agency. Interviews with facility staff revealed inconsistent understanding and application of reporting requirements. The Administrator and Director of Nursing described processes that involved verifying allegations before reporting, rather than immediately reporting all allegations as required by policy. Staff interviews indicated a lack of clarity about when and how to escalate allegations of abuse or misappropriation, leading to failures in timely and complete reporting to the appropriate authorities.
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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 Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fremont Healthcare Center | 0.7 mi | ★★★★★ | 30 | 0 |
| Crestwood Treatment Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Country Drive Post Acute | 1.4 mi | ★★★★★ | 4 | 0 |
| We Care Skilled Nursing - Fremont | 1.5 mi | ★★★★★ | 3 | 0 |
| Mission Valley Post Acute | 1.6 mi | ★★★★★ | 0 | 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.