Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Crestwood Manor during CMS and state inspections, most recent first.
A resident with a history of falls and multiple risk factors was left unsupervised in the bathroom after declining help, despite care plan interventions requiring staff assistance during toileting. The resident attempted to transfer herself, fell, and sustained a severe ankle fracture that required emergency care and surgery. Staff failed to notify others or use the emergency call system, and did not follow established fall prevention protocols.
The facility failed to obtain written consent for in-room camera monitoring for two residents, breaching their privacy rights. One resident had schizophrenia and impaired cognitive skills, while the other had intact cognition and was at moderate risk for falls. Monitors were used outside their rooms without consent, contrary to the facility's policy on resident privacy.
The facility failed to implement care plans for in-room camera monitoring for two residents, despite the presence of monitors outside their rooms. One resident had a history of schizophrenia and cognitive impairment, while the other had delusional disorders and mild cognitive impairment. Interviews with staff confirmed the absence of care plans for the camera use intended for fall and safety monitoring.
A facility failed to implement enhanced barrier precautions during wound care for a resident with a stage 2 pressure ulcer. Despite the resident's care plan requiring specific wound care procedures, a CNA and an LVN did not wear the necessary gown, only using gloves and masks. Interviews with staff confirmed the expectation to use full PPE to prevent infection spread, highlighting a lapse in adherence to infection control policies.
Failure to Provide Adequate Supervision for High Fall Risk Resident During Toileting
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls due to multiple medical conditions including schizoaffective disorder, metabolic encephalopathy, unsteady gait, repeated falls, and vertigo, was not provided with adequate supervision during toileting. The resident had a documented history of falls and was enrolled in the facility's Falling Star Program, which visually identified her as a fall risk. Despite care plan interventions specifying that staff should fully assist the resident during restroom use and ensure safety during transfers, these interventions were not followed on the day of the incident. On the day of the event, the resident called out for help to use the bathroom, but staff did not respond promptly. The resident independently used her wheelchair to access the bathroom. A staff member responded to the resident's wheelchair alarm, found her in the bathroom, and offered assistance, which the resident declined. The staff member then left the resident alone in the bathroom, did not notify other staff, and did not activate the emergency call light. Shortly after, the resident attempted to transfer herself from the toilet to her wheelchair, which was not locked, and fell, resulting in a severe right ankle fracture. Interviews and record reviews confirmed that the resident required supervision or touching assistance with toileting, as indicated in her care plan and MDS assessment. Staff acknowledged awareness of the resident's fall risk status and the need for supervision, but failed to implement the required interventions. The resident suffered a displaced bimalleolar ankle fracture, required emergency transport, pain management, and subsequent surgery to repair the injury.
Failure to Obtain Consent for In-Room Camera Monitoring
Penalty
Summary
The facility failed to obtain written consent for in-room camera monitoring for two residents, leading to a breach of privacy. Resident #103, admitted in 2017, had a medical history of schizophrenia and adverse effects from antipsychotics, with moderately impaired cognitive skills. A monitor was observed outside their room, and staff confirmed it was used for the resident. Similarly, Resident #124, admitted in 2022, had intact cognition and was at moderate risk for falls. A monitor was also observed outside their room, and staff stated it was used to watch the resident for falls. The facility's policy on resident rights emphasizes privacy in treatment and care, yet the Administrator admitted there was no written consent for the use of cameras. The facility document titled 'Consent for Identification Photograph' mentioned the use of audio or video recording, but it was undated and did not specifically address the consent for in-room monitoring. The lack of written consent for camera use in both cases constitutes a failure to uphold residents' privacy rights as per the facility's policy.
Failure to Implement Care Plans for Camera Monitoring
Penalty
Summary
The facility failed to implement a care plan for in-room camera monitoring for two residents, which was identified during a survey. Resident #103, who was admitted with a medical history of schizophrenia and adverse effects of unspecified antipsychotics, had a significant change in status indicating moderately impaired cognitive skills and a potential for falls. Despite the presence of a monitor outside the resident's room, there was no documented intervention in the care plan for the use of a camera monitor. Similarly, Resident #124, admitted with diagnoses including delusional disorders and mild cognitive impairment, was identified as a moderate risk for falls. A monitor was also observed outside this resident's room, yet there was no documented intervention in the care plan for camera use. Interviews with facility staff, including the Administrator, ADON, and DON, confirmed the absence of care plans for the camera monitoring intended for fall and safety monitoring of these residents.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with a stage 2 pressure ulcer. The resident, who was admitted in 2020, had a medical history of urinary incontinence and a non-pressure chronic ulcer. The resident's care plan included specific instructions for wound care, which required the use of normal saline, hydrogel, and a waterproof dressing. However, during an observation, a CNA and an LVN provided wound care without wearing the required gown, only using gloves and masks. Interviews with the LVN, Infection Preventionist, and Director of Nursing revealed that staff were expected to use gowns, gloves, and masks as part of EBP for residents with open wounds to prevent the spread of infection. The Infection Preventionist confirmed that the staff should have worn all necessary personal protective equipment (PPE) during the wound care procedure. The Director of Nursing expressed an expectation for staff to be aware of and utilize EBP for resident safety, indicating a lapse in adherence to the facility's infection control policies.
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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 Modesto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Modesto Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Modesto Post Acute Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Valley Skilled Nursing Center | 1.2 mi | ★★★★★ | 3 | 0 |
| River View Post Acute | 1.5 mi | ★★★★★ | 35 | 0 |
| Garden City Healthcare Center | 2.2 mi | ★★★★★ | 20 | 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.