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 Crestmoor Care Center during CMS and state inspections, most recent first.
Multiple residents experienced physical and verbal abuse from other residents, including repeated altercations between two individuals with cognitive and behavioral issues, and an incident involving a resident returning intoxicated and assaulting his roommate. Staff interventions, such as separation and periodic checks, were ineffective, and required documentation and monitoring were not consistently completed. Staff interviews revealed uncertainty and lack of recent training in managing aggressive behaviors, and leadership acknowledged gaps in staff education.
A resident with severe cognitive impairment and delusional disorder alleged that staff and other residents were trying to harm her. After leaving the facility and being found at a nearby store, she returned visibly upset. Although the resident was assessed and monitored, the facility delayed initiating a thorough investigation, did not promptly interview all relevant parties, and failed to follow its abuse policy for immediate response and reporting.
The facility failed to maintain sanitary conditions for food storage and handling. Observations revealed expired and unlabeled food items in nourishment refrigerators, improper temperature maintenance, and inadequate monitoring. Additionally, a dietary aide used the same gloves for multiple tasks during meal preparation, violating food safety standards. Staff interviews indicated unclear responsibilities for monitoring food safety.
The facility exhibited significant infection control deficiencies, including improper cleaning techniques by housekeeping staff, failure to implement Enhanced Barrier Precautions for residents with indwelling devices, and inadequate infection control during catheter and tracheostomy care. Staff did not consistently perform hand hygiene, disinfect high-touch surfaces, or use appropriate personal protective equipment, compromising the facility's infection prevention efforts.
The facility failed to maintain the dignity of three residents. A resident with cognitive impairment was subjected to undignified comments by a housekeeper about the odor in his room. Another resident was inappropriately guided by a nurse using the waistband of her pants. A third resident, resistant to care, was observed wearing soiled and ill-fitting clothing for several days, leading to a dignity issue when his pants fell in a public area.
The facility failed to prevent elopement for two residents with cognitive impairments, leading to incidents where they left the premises unsupervised. Additionally, a resident was not adequately supervised while smoking, and fall prevention measures were inconsistently applied for another resident. These deficiencies highlight lapses in implementing care plans and ensuring resident safety.
The facility failed to properly store and label medications in two of four medication carts, with expired medications not removed and injectable medications not labeled with opening dates. Loose pills were found in the carts, and staff interviews revealed a backlog in discarding old medications due to limited staff availability.
The facility failed to implement its policy on food storage, leading to unsafe conditions. Observations showed residents' refrigerators contained unlabeled and undated items stored at unsafe temperatures. Interviews revealed inconsistent monitoring and unclear responsibilities among staff, contributing to the deficiency.
The facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in care. A resident with dysphagia was not repositioned for eating and lacked supervision, another with severe cognitive impairment experienced delays in eating assistance, and a third resident with quadriplegia did not receive timely repositioning, bathing, or oral care.
A resident reported missing four pairs of pants after they were sent to the laundry, but the facility initially agreed to replace only two pairs. The grievance process, which began months earlier, was not resolved until the facility agreed to replace all four pairs. The facility's grievance policy requires prompt resolution, but delays in processing and communication led to the deficiency.
Two residents in an LTC facility did not receive timely and appropriate pressure ulcer care. One resident's care plan was delayed by seven days, and dressing changes were not conducted as ordered. Another resident was not provided with a pressure-relieving mattress for a month, and their care plan was initiated late. Staff interviews revealed a lack of awareness and communication regarding wound care needs.
A resident with an indwelling catheter did not receive appropriate care due to the facility's failure to obtain a physician's order, create a care plan, and maintain proper documentation. Observations showed improper infection control practices by an LPN, and staff interviews revealed inconsistencies in catheter care responsibilities and documentation. The DON acknowledged the lack of a care plan and physician's order, attributing it to an oversight during admission.
Two residents in a facility experienced abuse; one faced verbal abuse during a meal service, while another was physically struck over a seating dispute. Despite staff presence, the verbal altercation was not promptly addressed, and the physical incident was not substantiated as abuse due to lack of harm. Both incidents involved residents with cognitive impairments and behavioral issues.
Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, including physical and verbal altercations between residents, as well as neglect in monitoring and documenting aggressive behaviors. Several incidents occurred between two residents with histories of cognitive impairment and behavioral disturbances, resulting in repeated episodes of yelling, hitting, grabbing, and pushing. Despite known histories of aggression and trauma, staff interventions were limited to separating the residents and placing them on periodic checks, which proved ineffective in preventing further altercations. Documentation of these incidents was inconsistent, with some episodes not recorded in the electronic medical record. One resident, with diagnoses of bipolar disorder, depression, and dementia, exhibited severe cognitive impairment and a pattern of aggressive behavior towards others. This resident was frequently observed wandering unsupervised in the facility, despite care plans indicating a risk for aggression. Another resident, with dementia and anxiety, reported fear and distress following these altercations, leading to self-isolation and avoidance of common areas. Staff interviews revealed uncertainty and lack of recent training in managing aggressive behaviors, and the facility's leadership acknowledged gaps in staff education and training compliance. Additional deficiencies were noted in the facility's response to a resident who returned intoxicated from a community outing and physically assaulted his roommate. Although the care plan required one-to-one observation when the resident was intoxicated, there was no documentation that this intervention was implemented. Behavioral tracking sheets also failed to record aggressive incidents as required. These failures resulted in multiple residents being subjected to abuse and neglect, contrary to facility policy and regulatory requirements.
Failure to Timely Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into allegations of abuse made by a resident with severe cognitive impairment and a history of delusional disorders. The resident, who was diagnosed with dementia and delusional disorders and had a BIMS score of zero, reported that staff and other residents were trying to harm her. On the evening in question, the resident left the facility and was found at a grocery store across the street, visibly upset and fearful, stating that other residents were trying to kill her. Upon her return, she was assessed for injuries and placed on 15-minute checks, but no immediate or comprehensive investigation was initiated at that time. The facility's abuse policy required immediate reporting and investigation of any suspected abuse, including interviewing all relevant parties and implementing interventions to ensure resident safety. However, the investigation into the resident's allegations was delayed. The social services director indicated that the administrator wanted to consult with superiors before starting the investigation, resulting in a lack of prompt action. Additionally, the family member interviewed during the investigation was not involved in the incident, and key individuals such as the resident's son and the pharmacist who interacted with the resident during the event were not contacted by facility staff for information about the incident. Staff interviews confirmed that the required process for abuse allegations was not followed as outlined in facility policy. The delay in initiating the investigation and the failure to interview all relevant parties, including those directly involved or with firsthand knowledge of the resident's statements and behavior, contributed to the deficiency. The facility did not ensure that all alleged violations were responded to appropriately and in a timely manner, as required by their own procedures.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in various areas, including the main kitchen, activities room, and nourishment refrigerators. Observations revealed improper storage of food items, such as expired and unlabeled products, in the nourishment room refrigerators. The south hall nourishment refrigerator contained expired items like thickened apple juice, yogurt, and milk, as well as an unidentified food item and an undated butter packet. The north hall nourishment refrigerator was found to be at an improper temperature of 56 degrees Fahrenheit, with items like an unlabeled applesauce container and a thawed nutritional dessert cup that should have been stored frozen. Temperature logs indicated consistent temperature issues without corrective actions being documented. Interviews with staff highlighted a lack of clarity and responsibility regarding the monitoring and maintenance of refrigerator temperatures and contents. Registered nurses and certified nurse aides indicated that dietary staff and night shift nurses were responsible for checking temperatures, but there was no clear accountability for checking the contents. The dietary manager acknowledged the temperature issues and the need for a new refrigerator, as well as the lack of daily checks on the south nourishment refrigerator. Additionally, the facility failed to handle ready-to-eat foods in a sanitary manner. During a lunch meal service observation, a dietary aide used the same pair of gloves to handle multiple food items, including hamburger buns, lettuce, onion slices, and potato chips, without changing gloves between tasks. This practice was contrary to professional standards, which require single-use gloves to be used for only one task to prevent cross-contamination. The dietary manager confirmed that ready-to-eat foods should be handled with clean gloves used only for one task.
Infection Control Deficiencies in Housekeeping and Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies in housekeeping practices. Housekeeping staff did not follow proper cleaning techniques, such as performing hand hygiene between glove changes and disinfecting high-touch surfaces like call lights and door handles. Observations revealed that housekeepers used the same mop head for different areas of a room and did not disinfect tools like chisels and toilet brushes between uses. These actions were contrary to the facility's policy and professional guidelines, which emphasize the importance of cleaning high-touch surfaces to prevent the transmission of pathogens. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations showed that staff did not wear gowns when providing care to residents with catheters or gastrostomy tubes, and there were no signs indicating the need for EBP on the doors of these residents' rooms. Interviews with staff revealed a lack of awareness and understanding of EBP requirements, leading to inconsistent use of personal protective equipment during high-contact care activities. Additionally, the facility did not adhere to proper infection control procedures for catheter and tracheostomy care. Staff were observed using improper techniques, such as wiping catheter tubing from the bag to the perineum and failing to maintain sterility during tracheostomy suctioning. Vital signs equipment was also not disinfected between residents, further compromising infection control efforts. These deficiencies highlight significant lapses in the facility's infection prevention and control practices.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that care for residents was provided in a manner that maintained or enhanced their dignity. Resident #15, who was moderately cognitively impaired, was subjected to undignified comments by a housekeeper. The housekeeper loudly remarked about the unpleasant odor in the resident's room and bathroom, which was audible to others in the hallway. This behavior was acknowledged by multiple staff members, including the social services director and the nursing home administrator, as a violation of the resident's dignity. Resident #69, who was severely cognitively impaired, experienced a breach of dignity when a registered nurse used the waistband of the resident's pants to guide her to a chair. This action was contrary to the facility's expectations for staff to use verbal guidance and eye contact to direct residents. Interviews with other staff members, including a restorative nurse aide and a certified nurse aide, confirmed that grabbing a resident by their clothes was inappropriate and not in line with proper care practices. Resident #64, who had moderate cognitive impairment, was observed wearing soiled and ill-fitting clothing for several days. Despite his resistance to care, staff failed to address his clothing situation in a timely manner, leading to a dignity issue when his pants fell to the floor in a public area. The director of medical records eventually assisted the resident in changing into clean clothes, but the delay in addressing his appearance was noted as a failure to maintain the resident's dignity.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for several residents, leading to multiple incidents of elopement, inadequate supervision during smoking, and inconsistent implementation of fall prevention measures. For two residents identified as elopement risks, the facility did not maintain person-centered interventions to prevent them from leaving the premises unsupervised. One resident, with severe cognitive impairment and a history of exit-seeking behavior, was able to leave the facility on two occasions despite having a wander alarm in place. The staff failed to update the care plan after these incidents, and interviews with staff revealed a lack of awareness of the resident's elopement attempts. Another resident, with moderate cognitive impairment and a history of impulsivity, was also able to leave the facility on two occasions. Despite having a wander alarm, the resident's care plan did not effectively prevent elopement, and staff interviews indicated a misunderstanding of the resident's behaviors and the effectiveness of the interventions in place. The facility's failure to implement effective elopement prevention strategies contributed to these incidents. Additionally, the facility did not provide appropriate supervision for a resident while smoking, as required by the care plan. The resident, who required supervision and the use of a smoking apron, was observed smoking without the apron and without adequate supervision. Furthermore, the facility failed to consistently implement fall prevention measures for another resident, whose bed was not kept in the lowest position as required by the care plan, increasing the risk of falls. These deficiencies highlight the facility's failure to adhere to care plans and policies designed to ensure resident safety.
Improper Storage and Labeling of Medications in Facility
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards in two of four medication carts. Observations revealed expired medications, such as vitamin C supplements, fish oil supplements, and a COVID-19 testing reagent, were not removed from the medication cart. Additionally, injectable medications, specifically insulin injection pens for four different residents, were not labeled with the date they were opened. Loose pills were also found in multiple drawers of the medication carts, indicating a lack of proper organization and storage. Interviews with staff highlighted systemic issues in medication management. RN #4 mentioned that the night shift nursing staff was responsible for cleaning the medication carts weekly. However, the Director of Nursing (DON) acknowledged that the over-the-counter medications should be reviewed daily and that there was a backlog in discarding old medications due to limited staff availability. The DON also noted that there should not be any loose pills in the medication carts, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary storage, handling, and consumption of food. Observations revealed that personal refrigerators of residents contained items that were unlabeled, undated, and stored at temperatures above the recommended 41 degrees Fahrenheit. Specifically, a resident's refrigerator contained a container of rice that was unlabeled and undated, and a bottle of chocolate syrup with an obscured expiration date. The temperature logs for these refrigerators showed that temperatures were not consistently recorded, and when recorded, they were above the safe limit, with no corrective actions taken by staff. Interviews with residents and staff highlighted a lack of clarity and responsibility regarding the monitoring of refrigerator temperatures and contents. Residents reported that maintenance staff checked refrigerator temperatures but not daily, and there was no checking of expired items. The dietary manager confirmed that refrigerators should be kept at 41 degrees Fahrenheit or below to prevent bacterial growth, and noted that several refrigerators had not been checked for days. The environmental services director stated that housekeeping staff were responsible for checking temperatures but not the contents, indicating a grey area in departmental responsibilities. This lack of consistent monitoring and unclear responsibilities contributed to the deficiency in maintaining safe and sanitary food storage conditions.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident #80, who had a history of cerebral infarction and dysphagia, was not repositioned appropriately for eating and did not receive adequate supervision during meals. Observations revealed that the resident was left lying flat in bed with meal trays placed out of reach, and staff failed to assist or supervise her eating, despite her need for assistance due to swallowing precautions. Resident #1, with severe cognitive impairment and dependency on staff for all ADLs, experienced delays in receiving eating assistance. Meal trays were repeatedly placed out of reach, and staff took extended periods to assist the resident, leaving her hungry and calling out for help. The care plan indicated the need for one-on-one assistance during meals, which was not consistently provided, leading to prolonged periods without food. Resident #53, who was dependent on staff for all ADLs due to quadriplegia and other medical conditions, did not receive timely repositioning, bathing, or oral care. Observations showed the resident had a strong body odor and white residue in her mouth, indicating a lack of personal hygiene care. The care plan required frequent repositioning and mouth care, but these were not adequately performed, as evidenced by the resident's condition during observations.
Failure to Promptly Resolve Resident Grievance on Missing Clothing
Penalty
Summary
The facility failed to promptly resolve a grievance filed by a resident regarding missing clothing items. The resident, who is cognitively intact and requires assistance with personal hygiene, reported missing four pairs of pants after they were sent to the laundry. Initially, the facility only agreed to replace two pairs, and the resident was dissatisfied with this resolution. The grievance process began in September 2024, but the facility did not successfully resolve the issue until February 2025, when they agreed to replace all four pairs of pants. The facility's grievance policy requires that residents be informed of investigation findings and corrective actions within five working days of filing a grievance. However, the facility did not adhere to this timeline, as evidenced by the grievance forms and interviews. The grievance form from September 2024 was not signed by the resident and lacked a date for the NHA's signature, indicating a delay in processing. The NHA acknowledged the resident's history of requesting replacements for missing pants and the facility's failure to resolve the issue promptly, which led to the deficiency.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent or heal pressure injuries for two residents. Resident #184 was admitted with an unstageable pressure wound to the coccyx, but the facility did not initiate a comprehensive skin care plan until seven days after admission. There were no physician orders for dressing changes for the coccyx wound until five days post-admission, and the dressing was not changed until seven days after admission. This delay in care was noted despite the presence of an air mattress and heel boots, which were intended to alleviate pressure. Resident #75 was admitted with pressure ulcers on the coccyx and both heels. The facility failed to provide timely wound prevention interventions, as the resident was not observed using a pressure-relieving mattress, and the care plan was not initiated until one month after admission. Observations revealed that the resident's heels were not consistently floated, and the coccyx wound was not covered with a dressing as ordered. The facility also delayed obtaining a physician's order for an alternating pressure mattress until one month after admission. Interviews with staff, including the WCP, DON, and CNAs, highlighted a lack of awareness and communication regarding the residents' wounds and necessary interventions. The DON acknowledged the need for timely treatment interventions to prevent further deterioration of wounds. The facility's failure to implement consistent and timely wound care interventions contributed to the deficiencies observed during the survey.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter, as per professional standards. The resident, who was cognitively intact and dependent on staff for most activities of daily living, had a history of urinary tract infections and was using a catheter to manage her condition. However, the facility did not obtain a physician's order for the catheter, did not create a care plan addressing its use, and failed to maintain proper documentation for the catheter care and maintenance. Observations revealed that a Licensed Practical Nurse (LPN) did not follow proper infection control practices while providing catheter care. The LPN did not wear a gown and used the same washcloth to clean both the resident's perineum and the catheter, which is against the facility's policy. The facility's policy requires the use of separate washcloths and the wearing of appropriate personal protective equipment (PPE) during catheter care to prevent infections. Interviews with staff indicated inconsistencies in catheter care practices and documentation. Certified Nurse Aides (CNAs) and Registered Nurses (RNs) provided conflicting information about who was responsible for catheter care and how it was documented. The Director of Nursing (DON) acknowledged the lack of a catheter care plan and the absence of a physician's order, attributing it to an oversight during the resident's admission process. This oversight led to a deficiency in the care provided to the resident, as the necessary protocols and documentation were not in place.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically verbal abuse in one case and physical abuse in another. In the first incident, a resident was subjected to verbal abuse by another resident during a lunch meal service. Despite the presence of nursing staff, the verbal altercation was not immediately addressed, allowing the situation to escalate. The resident who was verbally abused expressed feeling upset and hurt by the derogatory remarks made by the other resident, who had a history of verbal aggression and cognitive impairments. In the second incident, a resident was physically abused by another resident over a seating dispute in the dining room. The assailant, who had a history of aggressive behavior, struck the victim with an open hand. Although staff intervened and separated the residents, the facility did not substantiate the incident as abuse, citing the lack of bodily harm or fear experienced by the victim. The assailant had been involved in previous aggressive incidents, highlighting a pattern of behavior that was not adequately managed. Both incidents reveal a failure in the facility's ability to prevent and address resident-to-resident abuse. The facility's policies and procedures for handling such situations were not effectively implemented, as evidenced by the delayed intervention and the lack of appropriate measures to prevent recurrence. The residents involved had documented cognitive impairments and behavioral issues, which were not sufficiently addressed to ensure a safe environment for all residents.
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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 Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkley Manor Care Center | 0.2 mi | ★★★★★ | 23 | 0 |
| Hilltop Park Post Acute | 0.8 mi | ★★★★★ | 1 | 0 |
| Rowan Community, Inc | 1.7 mi | ★★★★★ | 3 | 0 |
| Amberwood Post Acute | 1.8 mi | ★★★★★ | 4 | 0 |
| Center At Lowry, Llc | 1.8 mi | ★★★★★ | 11 | 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.