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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestwood Ridge Skilled Nursing And Rehab during CMS and state inspections, most recent first.
A resident was assaulted by another resident during a verbal altercation on the smoking patio, resulting in a mild closed head injury and other minor injuries. Despite having a care plan to manage aggressive behaviors, the facility failed to prevent the incident, indicating a deficiency in protecting residents from abuse.
The facility did not serve all items from the preplanned menu during a meal service, affecting all 44 residents. The menu included wheat bread, which was not served. The Dietary Manager confirmed the oversight.
The facility did not hold QAPI meetings at least quarterly and failed to have all required members in attendance. A meeting in January 2024 lacked the presence of a leadership figure, and there was no meeting documented for the second quarter of 2024. The administrator confirmed these issues.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage bag visible from the doorway without a dignity bag, contrary to the facility's policy. The resident, who had intact cognition and diagnoses including muscle weakness and cerebral palsy, was affected by this failure to maintain dignity.
A facility failed to notify a physician of a resident's blood glucose levels exceeding 400 mg/dL, as ordered. The resident, with multiple health conditions including diabetes, had blood glucose levels above 400 mg/dL on twelve occasions over a month, but the physician was only notified four times. This deficiency was confirmed through medical record reviews and staff interviews.
The facility failed to provide a SNF ABN to three residents after their Medicare Part A services were discontinued. These residents, who had various medical conditions and cognitive impairments, did not receive the required notice after their skilled services were cut. An RN confirmed the oversight during an interview.
A facility failed to complete a Significant Change in Status MDS assessment for a resident enrolled in hospice care. The resident, with multiple diagnoses including dementia and adult failure to thrive, was admitted to hospice, but the required assessment was not conducted within 14 days. This was confirmed by an LPN and through medical record review.
The facility failed to update PASARR documents for two residents, resulting in inaccuracies regarding their current conditions and diagnoses. One resident had a new diagnosis of bipolar disorder, and another had a new diagnosis of schizoaffective disorder, but these were not reflected in their PASARR assessments. This was confirmed by a regional nurse.
A facility failed to develop a care plan for a resident with PTSD, despite the resident being cognitively intact and having multiple diagnoses, including traumatic brain injury and paranoid schizophrenia. The absence of a care plan was confirmed during a staff interview, highlighting a deficiency in addressing the resident's emotional and behavioral needs.
A facility failed to notify a resident's legal guardian in writing when the resident was transferred to the hospital after swallowing batteries. The resident, with multiple mental health diagnoses and moderate cognitive impairment, was unable to return to the facility post-hospitalization. Attempts to contact the guardian were unsuccessful due to a disconnected phone number, and no written notification was documented.
A facility failed to provide a written bed-hold notice to a resident and their legal guardian during a hospital transfer. The resident, with multiple diagnoses and moderate cognitive impairment, was sent to the ER after swallowing batteries. The facility's policy required notification about bed-hold days, but there was no evidence the guardian received this information. The resident was not permitted to return post-hospitalization, and the administrator confirmed the oversight, resulting in a deficiency.
A facility failed to readmit a resident after hospitalization, despite the resident's lack of capacity to sign out AMA and having a legal guardian. The resident, with a history of mental health issues, was treated for ingesting batteries and was ready for discharge back to the facility. The facility's administrator refused to accept the resident back, violating the resident's rights, and did not issue a required 30-day discharge notice. The resident was eventually discharged to another facility.
A resident with a history of non-compliance was left outside in extreme heat without adequate supervision, resulting in hyperthermia and hospitalization. The facility failed to document increased supervision or educate the resident on the risks of extreme weather, leading to a deficiency in care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in an incident where Resident #12 was assaulted by Resident #39. Resident #12, who was cognitively intact and used a wheelchair, was punched in the face by Resident #39 during a verbal altercation on the smoking patio. This assault led to Resident #12 being temporarily unconscious and subsequently diagnosed with a mild closed head injury, lip abrasion, and cervical strain after being evaluated at a local hospital. Resident #39, who also used a wheelchair and was cognitively intact, had a history of various mental health diagnoses, including paranoid schizophrenia and schizoaffective disorder. The care plan for Resident #39 included interventions for managing behaviors such as aggression and verbal outbursts. Despite these interventions, Resident #39 engaged in a physical altercation with Resident #12, demonstrating a failure in the facility's ability to manage and prevent aggressive behaviors effectively. The incident was documented by RN #290, who witnessed the altercation and attempted to intervene. The local police were involved, and the incident was under investigation for disorderly conduct. The facility's policy on abuse prohibition was reviewed, which stated that residents should not be subjected to abuse or mistreatment by anyone. However, the policy's implementation was inadequate in preventing the assault on Resident #12, indicating a deficiency in ensuring resident safety and protection from abuse.
Failure to Serve Complete Preplanned Menu
Penalty
Summary
The facility failed to serve all food items from the preplanned menu during a meal service, which had the potential to affect all 44 residents in the facility. The dietary menu for a specific date indicated that the meal should include spaghetti sauce with meatballs, pasta, green beans, wheat bread, margarine, and cake. However, during an observation, it was noted that the cook prepared and served the meal without the wheat bread, as specified in the menu. An interview with the Dietary Manager confirmed that the wheat bread was supposed to be included in the meal and acknowledged that it was not served. The Dietary Manager admitted that the omission of the bread from the meal trays was due to an oversight.
QAPI Meeting Attendance and Frequency Deficiency
Penalty
Summary
The facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly and did not ensure the presence of all required members during these meetings. Specifically, the QAPI meeting sign-in sheet from January 11, 2024, indicated the absence of the facility's administrator, owner, board member, or another individual in a leadership role. Additionally, there was a significant gap between meetings, with one held on March 12, 2024, and the next not occurring until August 22, 2024. There was no documentation of a QAPI meeting for the second quarter of 2024, covering April, May, or June. The administrator confirmed these deficiencies during an interview on December 12, 2024.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling urinary catheter by not covering the catheter drainage bag with a dignity bag. This deficiency was identified through observations, staff interviews, and a review of the facility's policy. The resident involved was admitted with diagnoses including muscle weakness, neuromuscular dysfunction, and spastic diplegic cerebral palsy, and was assessed to have intact cognition. The facility's policy required the use of a Foley catheter privacy bag, which was not adhered to in this case. During multiple observations over three consecutive days, the resident was seen lying in bed with the door open, and the Foley catheter drainage bag was visible from the doorway without a dignity bag covering it. The yellow urine was visible in the tubing and drainage bag, which was confirmed by the Activity Director during one of the observations. The facility's policy on Foley catheter care explicitly stated that the drainage bag should be placed inside a privacy bag, which was not done, leading to the deficiency in maintaining the resident's dignity.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a physician of a resident's blood glucose levels when they exceeded 400 mg/dL, as per the physician's orders. This deficiency was identified during a review of the medical records and staff interviews. The resident involved had multiple health conditions, including type two diabetes mellitus, severe protein calorie malnutrition, respiratory failure, major depressive disorder, generalized anxiety disorder, and dysphagia. The physician's order specified that for blood glucose levels above 400 mg/dL, 12 units of insulin should be administered, and the physician should be notified. However, from November 10, 2024, to December 9, 2024, the resident's blood glucose levels exceeded 400 mg/dL on twelve occasions, but the physician was only notified four times. Specific instances where the physician was not notified include blood glucose levels of 432 mg/dL, 500 mg/dL, 408 mg/dL, 426 mg/dL, 567 mg/dL, 498 mg/dL, 520 mg/dL, 450 mg/dL, 411 mg/dL, 418 mg/dL, 488 mg/dL, and 511 mg/dL. This failure to notify the physician as ordered was confirmed during an interview with the Regional Nurse.
Failure to Provide SNF ABN After Medicare Service Termination
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to residents after their Medicare Part A services were discontinued. This deficiency affected three residents who were reviewed during the survey. Resident #04, who was admitted with diagnoses including diabetes mellitus, schizoaffective disorder, and schizophrenia, was found to be mildly cognitively impaired. Despite receiving a Medicare cut letter indicating the cessation of skilled services, the facility did not provide the required SNF ABN. Similarly, Resident #28, admitted with conditions such as urinary tract infection, asthma, and major depressive disorder, was also mildly cognitively impaired. The facility failed to issue a SNF ABN after her Medicare skilled services were cut. Resident #40, with diagnoses including dementia and anxiety disorder, was cognitively impaired and did not receive a SNF ABN following the termination of his Medicare skilled services. An interview with the Regional Nurse confirmed that these residents remained in the facility without receiving the necessary SNF ABN.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was enrolled in a hospice program. The resident, who had multiple diagnoses including dyskinesia, psychosis, hypertension, dementia, and adult failure to thrive, was admitted to hospice services. Despite the change in condition and the initiation of hospice care, the facility did not conduct the required MDS assessment within 14 days of the resident's enrollment in hospice. This oversight was confirmed through a review of the resident's medical records and an interview with the MDS Licensed Practical Nurse (LPN), who acknowledged the failure to complete the assessment.
Failure to Update PASARR Documents for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASARR) documents were accurate and updated to reflect the current conditions and diagnoses of residents. This deficiency was identified during a review of two residents' records. Resident #27 was admitted with multiple diagnoses, including nephropathy, type two diabetes mellitus, and anxiety disorder. On 05/15/24, a new diagnosis of bipolar disorder manic without psychotic features was added to Resident #27's medical record. However, the PASARR document dated 09/08/23 was not updated to include this new diagnosis, as confirmed by an interview with Regional Nurse #200. Similarly, Resident #23 was admitted with diagnoses such as anxiety disorder and senile degeneration of the brain. A new diagnosis of schizoaffective disorder was added on 11/14/23. Despite this addition, the PASARR assessments for Resident #23 were not updated to reflect the new mental health diagnosis. This was verified through an interview with Regional Nurse #200, who confirmed that a new PASARR assessment was not completed following the addition of the new diagnosis. The facility's failure to update PASARR documents for these residents indicates a lapse in maintaining accurate and current records for resident care.
Failure to Develop PTSD Care Plan
Penalty
Summary
The facility failed to develop a care plan to address a resident's post traumatic stress disorder (PTSD), which was identified during a medical record review and staff interview. This deficiency affected one resident who was reviewed for behavior and emotional needs. The resident, admitted with multiple diagnoses including traumatic brain injury, paranoid schizophrenia, and PTSD, was cognitively intact and used a wheelchair for mobility. Despite being coded with a PTSD diagnosis in the quarterly Minimum Data Set (MDS) assessment, there was no care plan in place to address the resident's PTSD and identified triggers. This was confirmed during an interview with the Regional Nurse, who verified the absence of a care plan for the resident's PTSD.
Failure to Notify Legal Guardian of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to the legal guardian of Resident #49 when the resident was transferred to the hospital. Resident #49, who had a court-appointed guardian and a Medicaid payor source, was admitted to the facility with multiple diagnoses, including unspecified psychosis, PTSD, bipolar disorder, schizoaffective disorder, COPD, suicide attempts, and intellectual disabilities. The resident had a BIMS score indicating moderate cognitive impairment. On the evening of 07/26/24, the resident informed a nurse that she had swallowed two AAA batteries, prompting her transfer to the emergency room. Despite attempts to contact the legal guardian, the facility was unable to reach them due to a disconnected phone number. The facility's records did not show any written evidence that the legal guardian was notified of the transfer at the time it occurred. A Transfer/Discharge Notice was documented, indicating the resident's transfer to the hospital due to possible self-harm, but there was no evidence that this notice was provided to or reviewed with the legal guardian. Additionally, the facility did not allow the resident to return following her hospitalization. An interview with the Administrator confirmed the transfer details but did not provide any additional information regarding notification to the legal guardian. This deficiency was investigated under Complaint Number OH00156427.
Failure to Provide Bed-Hold Notice to Resident's Guardian
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident and their legal guardian at the time of the resident's transfer to the hospital, as required by regulations. The resident, who had a court-appointed guardian and a Medicaid payor source, was admitted with multiple diagnoses including unspecified psychosis, PTSD, bipolar disorder, schizoaffective disorder, COPD, suicide attempts, and intellectual disabilities. The resident had a BIMS score indicating moderate cognitive impairment. On a specific date, the resident was sent to the emergency room after claiming to have swallowed two AAA batteries, and the facility's records showed that the guardian's contact number was disconnected. The facility's documentation included a Transfer/Discharge Notice, which was reviewed by the social service director and the resident, but there was no evidence that the legal guardian was provided with this notice or informed about the bed-hold policy. The facility's policy stated that residents or their representatives should be notified about the number of bed-hold days available on the first business day following a transfer. However, there was no record of the guardian receiving this information. Additionally, the facility did not permit the resident to return following hospitalization. The administrator confirmed that the legal guardian was not provided with the required bed-hold notice, leading to a deficiency under Complaint Number OH00156427.
Facility Refusal to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow Resident #49 to return after hospitalization, violating the resident's rights. Resident #49, who had a history of mental health issues and cognitive impairment, was sent to the emergency room after ingesting batteries. After treatment, the resident was ready to return to the facility, but the facility refused to accept her back, claiming she was a community member after leaving the hospital against medical advice (AMA). The facility's refusal persisted despite the hospital's communication that the resident lacked the capacity to sign out AMA due to having a legal guardian. The hospital staff informed the facility that the resident was still under their care and required a 30-day discharge notice, which the facility did not issue. The facility's administrator was adamant about not taking the resident back, even after being informed by the hospital and the Ombudsman that this was a violation of the resident's rights. The hospital staff continued to seek a new discharge location for the resident, as the facility maintained its refusal. The facility instructed its staff not to communicate with the hospital regarding the resident, further complicating the discharge process. Ultimately, the resident was discharged to another appropriate facility for ongoing care, highlighting the facility's non-compliance with regulations regarding resident readmission after hospitalization.
Inadequate Supervision Leads to Resident Hyperthermia
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from experiencing hyperthermia during extreme weather conditions. Resident #8, who was cognitively intact but had a history of non-compliance with safety measures, was left outside for an undetermined amount of time on a day when temperatures reached 90 degrees Fahrenheit. The resident was later found with a high temperature of 103 degrees Fahrenheit, confusion, and low blood pressure, leading to a diagnosis of hyperthermia and subsequent hospitalization. The medical record review revealed minimal documentation regarding Resident #8's refusal of care and education about the health risks associated with non-compliance. There was no documentation indicating that staff provided increased supervision or hydration during the extreme weather conditions. Interviews with staff and residents confirmed that Resident #8 was outside for a significant amount of time without adequate supervision, and staff failed to document or act upon the resident's refusal to come inside during the extreme heat. The facility's policy on accidents and hazards required the implementation of interventions consistent with residents' needs, including adequate supervision. However, the facility did not document any increased supervision levels or education provided to Resident #8 regarding the risks of extreme weather conditions. The lack of documentation and supervision contributed to the resident's hyperthermia and subsequent hospitalization, representing a deficiency in the facility's care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillsboro Post Acute | 1.5 mi | ★★★★★ | 0 | 0 |
| Hillsboro Health And Rehab Llc | 1.5 mi | ★★★★★ | 3 | 1 |
| Edgewood Manor Of Greenfield | 15.9 mi | ★★★★★ | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 16.4 mi | ★★★★★ | 5 | 0 |
| Monarch Meadows Nursing And Rehabilitation | 17.2 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Crestwood Ridge Skilled Nursing And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.