Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Crest Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure the DON worked full-time as DON duties were combined with Infection Preventionist responsibilities. Staff stated the DON also served as the infection preventionist, spending 20 hours per week on infection control and the rest on DON duties, while the facility assessment showed only two administrative nurses covering multiple administrative nursing responsibilities. The DON job description listed infection control duties but did not identify the role as a dual position.
A resident with severe cognitive impairment was sexually assaulted by another resident with a history of sexually inappropriate behavior, and the record did not show psychosocial assessments or care plan updates tied to the event. In a separate incident, another resident was struck in the head and neck by a different resident during a meal, and the facility did not document daily physical and psychosocial assessments afterward; a bruise was later noted on the resident’s neck.
A resident was observed in bed with upper and lower bed rails in place, with open areas and spacing that could allow entrapment. Staff gave inconsistent explanations for why the rails were being used, and the care plan listed rail use as an intervention but did not show revised interventions for monitoring the resident’s ongoing bed rail use.
A resident was observed in bed with full upper and lower bed rails on both sides, with open areas and spacing between the rails creating a potential entrapment concern. Staff gave inconsistent explanations for the rails, including TBI, agitation, fall prevention, and repositioning, but the record lacked a documented medical rationale, an entrapment assessment, documented alternatives, and a physician-signed order; consent forms also listed different indications for the upper and lower rails.
Food service leadership did not meet CMS qualification requirements, and the facility did not employ a full-time onsite RD. Staff stated the food service manager had no dietary manager certification or approved course enrollment, despite prior dietary management experience, and the dietician only visited intermittently while a remote dietician assisted with menus and other duties.
The facility failed to ensure that licensed nursing staff adhered to prescribed oxygen delivery rates for three residents. Records showed that oxygen levels frequently exceeded the prescribed limits, despite facility policy requiring adherence to physician orders. Interviews confirmed that nursing staff were aware of the need for provider orders to change oxygen rates.
The facility failed to manage portable oxygen tanks properly, resulting in a resident's oxygen saturation dropping to 86%. Staff interviews revealed that tanks were not replaced promptly, and there was a lack of documentation for provider notifications and interventions when oxygen levels fell below 90% for two residents. Records showed numerous omissions in documenting oxygen settings over several months.
The facility failed to change and label oxygen tubing for four residents requiring respiratory care, despite the protocol for weekly changes. Observations and staff interviews revealed inconsistencies in following the protocol, with some tubing not labeled or changed as required. The TAR indicated the changes were documented, but observations suggested otherwise.
The facility failed to ensure a resident's GDR request for fluoxetine was responded to by the physician and completed. Despite multiple GDR requests from the consultant pharmacist, there was no response until the surveyors intervened. Staff interviews indicated a lack of documentation and timely action regarding the GDR request.
DON Not Worked Full-Time as Required
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) worked full-time as the DON, defined by CMS as 40 hours or more per week. During an interview, staff member A stated the facility employed a full-time DON and did not have any nurse staffing waivers in place. However, during later interviews, staff member B stated she served as both the infection preventionist and the DON, and that she dedicated 20 hours per week to infection control with the remainder of her time spent on DON responsibilities. Staff member A also stated staff member B could complete both roles within a 40-hour work week because of the facility’s size and low census, and that she never went into overtime. Record review showed the facility assessment listed administrative nursing responsibilities for infection control, employee health, outbreak management, regulatory requirements, quality assurance/performance improvement, staffing and supply control, MDS and quality measure information, five-star ratings, pharmacy recommendations, consultant reports, MD communications, medical director communications, nurse practice act, residents’ rights, fire safety, abuse identification, prevention and reporting, and customer service. The facility assessment identified only two administrative nurses covering these responsibilities. Review of the DON job description showed the DON was responsible for infection control program duties, but it did not identify the DON position as a dual role requiring the DON to also serve as the Infection Preventionist.
Failure to Protect Residents from Abuse and Monitor Post-Incident Harm
Penalty
Summary
The facility failed to protect a vulnerable resident from non-consensual sexual contact by another resident with a history of sexually inappropriate behavior. A resident with severe cognitive impairment was observed with another resident lifting her shirt and holding her breast. A staff witness immediately removed the resident from the area, and the resident later acknowledged touching someone’s breast and stated he was not allowed to do that. The record showed the resident who committed the act had diagnoses including paranoid schizophrenia, hypersexuality, and dementia without behavioral disturbance, and the facility noted he had a history of sexually inappropriate behavior toward female residents. After the incident, the resident who was touched did not have documented psychosocial evaluations related to the sexual abuse, and the electronic record did not show follow-up nursing progress notes, new tasks or interventions, or care plan updates tied to the event. The incident report included a special care remark to redirect away from the male resident and keep at least six feet away, but the record did not show documentation of the resident’s psychosocial response to the abuse. Staff stated the resident was unaware of the incident and that no psychosocial assessments were completed because she did not remember it. The facility also failed to adequately monitor physical and psychosocial harm for another resident after an abuse incident involving a different resident who struck him in the head and neck during a meal. The assaulted resident later reported the hit hurt and that the other resident punched people randomly. Although the facility documented some follow-up, the record did not show daily physical and psychosocial assessments after the incident. A bruise measuring 6.3 cm by 5.2 cm was later documented on the back of the resident’s neck, and the facility’s notes reflected limited follow-up documentation after the event.
Failure to Revise Care Plan for Bed Rail Monitoring
Penalty
Summary
The facility failed to revise resident #43’s care plan to include interventions that were effective in monitoring the resident’s ongoing use of bed rails, resulting in inconsistent reasoning among staff for why the rails were being used. During observation, resident #43 was found in bed with upper and lower bed rails in place, and both sets of rails had open areas with potential for arm entrapment, along with space between the upper and lower rails that could have the potential for limb entrapment. Staff interviews showed differing explanations for the bed rail use and monitoring. One staff member stated all four rails were to be up while the resident was in bed and that the rails helped with repositioning, while another stated bed rails were part of the MDS assessment and should be included on the care plan and reassessed with changes in condition, general nursing assessment, and quarterly review. Additional staff stated one employee was responsible for assessing the need for upper bed rails and adding them and related interventions to the care plan, and another stated the rails should be assessed every quarter and as needed. Review of the care plan showed interventions related to using rails on the bed to decrease falls with agitation, but the report did not show a revised care plan with specific interventions for monitoring the resident’s ongoing bed rail use.
Bed Rails Used Without Complete Assessment, Rationale, or Physician Order
Penalty
Summary
The facility failed to ensure bed rails were assessed for entrapment, failed to assess other alternatives before use, failed to document a medical rationale for the bed rails, and failed to have a physician-signed order for the bed rails for resident #43. The resident was observed in bed with full upper and lower bed rails on both sides of the bed, and on another observation was sleeping with the head of the bed elevated while open areas on the upper and lower rails and the space between the rails created a potential entrapment concern. Staff stated the resident was to have all four rails up while in bed, that he had been evaluated by physical therapy, and that someone was always in the room during repositioning. Staff also stated the resident had a traumatic brain injury, was aggressive and not easily redirected, could possibly reposition himself, and used the rails for repositioning and to keep him from falling off the bed. Record review showed inconsistent documentation for the bed rails. The care plan listed different reasons over time, including sleep disturbance, disruptive interaction, aggression, agitation, trauma, and falls, while the consent forms listed different indications for the lower and upper rails, including TBI, impulsivity, agitation, family request, and increased bed mobility. The bed rail assessment dated 10/30/25 stated the rails were for assistance with bed mobility, to prevent rolling and falling out of bed, and for comfort and security, and noted the device was appropriate, consent should be obtained, and an order should be obtained. The care plan entries dated 11/24/25, 1/3/26, and 1/28/26 did not show alternative interventions used prior to continued bed rail use, and the facility did not provide a signed physician order, complete an entrapment assessment, document a rationale for use, or document alternatives used before the bed rails were used.
Food Service Director Qualification and Dietician Staffing Deficiency
Penalty
Summary
The facility failed to ensure the director of food and nutrition services met the education qualifications required by CMS for a food service director and failed to employ a full-time dietician. During an interview, staff member E stated she did not have a dietary manager certification and had not enrolled in or completed an approved dietary manager certification course. She also stated the dietician came to the facility once every two weeks to evaluate residents and that she would call the dietician with questions or concerns. During a later interview, staff member A stated staff member E had not completed a dietary manager certification course but had five years of experience in dietary management before being hired in 2024. Staff member A stated she believed that prior experience was enough to meet the CMS requirement for dietary managers. Staff member A also stated the dietician visited the facility twice a month, the facility had a remote dietician who assisted with menus and other dietary duties, and the facility did not employ an onsite full-time dietician. Review of staff member E's education records showed continuing education hours in multiple areas, but no evidence of completion of a certified dietary manager course. Review of the facility's job title document for Food Service Manager stated the qualification requirement included successful completion or current enrollment in a course approved by the American Dietetic Association.
Failure to Adhere to Prescribed Oxygen Delivery Rates
Penalty
Summary
The facility failed to ensure that licensed nursing staff adhered to accepted standards of practice by administering oxygen within the parameters of the provider's orders for three residents prescribed supplemental oxygen. For Resident #5, the Treatment Administration Record showed that from September 2024 through March 2025, the oxygen levels delivered frequently exceeded the prescribed one liter per minute. Similarly, Resident #6's records indicated that from October 2024 through January 2025, the oxygen levels delivered often exceeded the prescribed two liters per minute. Resident #4's records from November 2024 through January 2025 also showed instances where the oxygen levels exceeded the prescribed maximum of two liters per minute. Interviews with staff members revealed that nursing was the only discipline allowed to change oxygen levels, and a new provider order was required to adjust a resident's oxygen rate of flow if it was outside the existing order parameters. The facility's policy, titled 'Oxygen - Appropriate Use, Management and Storage,' emphasized that oxygen should be treated as a medication, and licensed nurses must follow a physician's order for oxygen delivery. Despite this policy, the facility's nursing staff did not consistently adhere to the prescribed oxygen delivery rates, leading to the identified deficiencies.
Failure to Manage Portable Oxygen Tanks and Document Interventions
Penalty
Summary
The facility failed to ensure proper management of portable oxygen tanks for residents requiring supplemental oxygen. Specifically, a resident was observed with a portable oxygen tank that was empty, resulting in an oxygen saturation level of 86%, below the prescribed threshold of 90%. Staff interviews revealed that while all staff were responsible for checking oxygen levels, there were instances where the tanks were not replaced promptly, leading to dangerously low oxygen levels. Despite staff awareness of the issue, the problem persisted, with one staff member expressing concern about the resident's oxygen levels dropping as low as 74%. Additionally, the facility did not consistently document provider notifications, nursing assessments, or interventions when residents' oxygen saturation levels fell below the prescribed parameters. For two residents, there were multiple occurrences where oxygen levels were below 90%, yet there was no documentation of any action taken. This lack of documentation spanned several months, indicating a systemic issue in monitoring and responding to residents' oxygen needs. The facility's records showed numerous omissions in documenting whether the oxygen was turned on and set at the correct flow rate. This lack of documentation was evident over several months, with multiple omissions each month. Staff interviews confirmed that vital signs, including oxygen levels, were checked by CNAs and reported to nurses if abnormal, but the follow-up actions were not consistently recorded in the residents' records.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to change and label resident oxygen tubing for four of five sampled residents requiring respiratory care. Resident #34 was observed with oxygen tubing labeled and dated thirteen days prior, despite the facility's protocol requiring weekly changes. Staff interviews revealed inconsistencies in following the protocol, with one staff member acknowledging the tubing should have been changed the previous week. Resident #34 had a history of respiratory failure and was on a reduced oxygen level. The Treatment Administration Record (TAR) indicated the tubing change was documented as completed, although observations suggested otherwise. Resident #33 was observed with undated oxygen tubing on two separate occasions. Staff interviews confirmed the protocol for weekly tubing changes, but the tubing was not labeled as required. The TAR showed the tubing change was documented, but observations did not align with this record. Resident #33 had diagnoses of pneumonia, COPD, and obstructive sleep apnea. Similar issues were observed with residents #4 and #28, where the oxygen tubing was either not labeled or not changed as per the facility's policy. The facility's policy on oxygen management required weekly changes and proper documentation, which was not consistently followed for these residents.
Failure to Ensure Timely GDR Response for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident's Gradual Dose Reduction (GDR) request for fluoxetine was responded to by the physician and completed. Resident #34 had a history of depression and was on fluoxetine, with dosage adjustments documented over time. Despite multiple GDR requests from the consultant pharmacist in January, February, and March 2024, there was no response from the physician until the surveyors requested the GDR form on March 27, 2024. The GDR response was completed by the physician on the same day it was requested by the survey team, indicating a delay in addressing the GDR request. Interviews with staff revealed that staff member B was responsible for ensuring GDR requests were responded to by the physician and for documenting conversations about GDRs. Staff member A mentioned that staff member D might have delayed the response due to the resident's hospice status, but there was no documentation to support this. The facility's policy on psychoactive medication protocol requires GDR attempts in two separate quarters within the first year unless clinically contraindicated, which was not adhered to in this case.
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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 Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continental Care And Rehabilitation | 0.2 mi | ★★★★★ | 1 | 0 |
| Copper Ridge Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 17 | 0 |
| Southwest Montana Veterans Home | 3.1 mi | ★★★★★ | 0 | 0 |
| Community Nursing Home Of Anaconda | 24 mi | ★★★★★ | 17 | 0 |
| Ivy At Deer Lodge | 30 mi | ★★★★★ | 10 | 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.