Below 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 Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Several residents reported that meals were cold, unappetizing, and sometimes insufficient, with observations confirming that food was served below recommended temperatures and appeared unappealing. Staff interviews revealed improper use of equipment to maintain food temperature due to shortages, and resident council minutes documented ongoing complaints about cold food.
A policy change restricted beverage options for residents, allowing only water between meals and limiting coffee and juice to meal times. The Dietary Supervisor confirmed that staff were instructed not to provide other beverages between meals, even upon request, due to cross contamination concerns. Residents expressed complaints about the new policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wander guard alarm in place. Staff failed to respond appropriately to the alarm, did not verify the resident's location, and turned off the alarm without notifying others, resulting in the resident being unsupervised outside the facility for several hours.
The facility failed to report investigation results to the SSA within 5 days for two residents. One resident experienced misappropriation of funds, and another sustained a fall resulting in a lumbar compression fracture. The ADM did not submit the required 359 forms within the 5-day timeframe, leading to the deficiency.
A resident's discharge planning was significantly delayed due to repeated issues with the NCW application process by the Resident Advocate (RA). The resident and their family experienced confusion and frustration as the RA failed to submit the correct paperwork for a year, leading to concerns about losing a room in the community.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
Surveyors identified that the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for three of nineteen sampled residents. Multiple residents reported dissatisfaction with the quality and temperature of the food, including complaints that meals were cold, unappetizing, and insufficient. One resident stated that the food tasted very poor and that breakfast consisted only of toast and coffee. Another resident reported that the food was served cold, while a third resident described the lunch as unappealing and did not eat it. Observations during trayline service revealed that food items, including popcorn chicken, rice, and brussel sprouts, were served at temperatures below recommended levels and were cold to the taste. The appearance and texture of the food were also noted to be unappetizing, with brussel sprouts described as mushy and discolored, and the dessert having an unusual flavor combination. Further investigation revealed that the kitchen staff did not consistently use the proper equipment to maintain food temperature, as there were not enough bases/liners for all residents, leading to the use of hot pellets alone, which did not retain heat adequately. Staff interviews confirmed that the correct procedure was not always followed due to equipment shortages. Resident council meeting minutes from several months also documented ongoing complaints about cold food, indicating a pattern of unresolved issues related to food service quality and temperature.
Failure to Provide Beverages Consistent with Resident Needs and Preferences
Penalty
Summary
The facility failed to provide beverages consistent with resident needs and preferences and sufficient to maintain hydration. A sign posted in the resident elevator announced a policy change restricting beverage availability, stating that only water would be provided between meals and that coffee and juice would only be served at meal times. Residents were informed that if they wanted beverages other than water between meals, they would need to provide their own, with vending machines planned for future installation. The Dietary Supervisor confirmed that this policy was implemented due to concerns about cross contamination from residents bringing their mugs to the kitchen, and that kitchen staff were instructed not to provide beverages other than water between meals, even if residents requested them. The Dietary Supervisor also acknowledged that residents had complained about the change since its implementation.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, including dementia and a history of alcohol dependence, was assessed as high risk for wandering and elopement. The resident had a documented history of increased wandering, previous elopement attempts, and impaired decision-making skills. The care plan included interventions such as the use of a wander guard alarm system, staff education on elopement policy, and engagement in purposeful activities. Despite these measures, the resident was able to exit the facility unsupervised and was missing for several hours. On the day of the incident, the resident exited the building, triggering the wander guard alarm. A staff member turned off the alarm without notifying other staff or verifying the resident's location. Other staff members assumed the resident was accounted for and did not physically check on him when the alarm sounded. The resident was later found outside the facility and returned by staff. Interviews revealed that staff were aware of the resident's elopement risk and the protocol for responding to wander guard alarms, which included verifying the location of all residents with wander guards and notifying staff via walkie talkies. However, these protocols were not followed during the incident. Documentation and interviews indicated that the resident had previously eloped, both before and after the implementation of the wander guard. The facility's policy stated that alarms are not a replacement for necessary supervision and that staff must respond to alarms promptly. The failure to respond appropriately to the wander guard alarm and to verify the resident's whereabouts resulted in the resident's unsupervised exit from the facility.
Failure to Report Investigation Results Timely
Penalty
Summary
The facility failed to report the results of all investigations to the State Survey Agency (SSA) within 5 days of the incident for two residents. Resident 1 experienced an allegation of misappropriation of funds when money went missing from his wallet. The Resident Advocate (RA) reported the incident to the Administrator (ADM), who reviewed footage but did not see anything conclusive. The ADM replaced the resident's money and educated him on keeping his money in the safe but failed to submit the required 359 form within the 5-day timeframe. Resident 2 sustained a fall resulting in a lumbar compression fracture. The initial report indicated an allegation of neglect. The resident's medical records showed that she had an unwitnessed fall and subsequent pain, leading to a CT scan that confirmed the fracture. The ADM interviewed staff and residents present during the incident but did not submit the 359 form within the required 5 days. Interviews with staff revealed a lack of awareness about the abuse coordinator and proper procedures for reporting falls and potential neglect. The ADM acknowledged the failure to submit the 359 forms within the required timeframe for both incidents. The facility's policy required the 358 form to be submitted within 2 hours and the 359 form within 5 days, but these requirements were not met. The ADM admitted to dropping the ball on these submissions, leading to the deficiency noted in the report.
Failure to Ensure Timely Discharge Planning
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and resulted in the development of a discharge plan. Specifically, a resident who desired to return to the community through the New Choice Waiver (NCW) program did not have the required paperwork submitted for a whole year. The resident's family member reported that the Resident Advocate (RA) initially submitted incorrect paperwork and did not follow up. Despite repeated requests from the family, the RA continued to have issues with the application process, leading to significant delays. The family member expressed concerns that the facility might have a financial incentive to keep the resident longer, and the resident was at risk of losing a room that was on hold for them in the community. The resident, who had moderate cognitive impairment, expressed confusion and frustration over the prolonged NCW application process. The resident stated that the RA repeatedly delayed the application process, pushing it back 90 days at a time. The resident's medical record indicated that the discharge goal was to return to the community, but there were no documented care conference summaries for the entire year of 2023 to indicate that the discharge goal had been updated or discussed. The RA acknowledged the gap in care conferences and admitted to issues with submitting the NCW application, including forgetting to check the correct boxes and uploading incorrect documents. The RA stated that the discharge planning started upon admission but changed throughout the resident's stay. The RA admitted that they should have applied for the NCW last year when the resident initially asked. The RA also mentioned that they were the only ones with access to the NCW system and had personal matters that delayed the application process. The RA recognized the family's frustration and acknowledged that the resident would not be discharged before the end of the month due to the NCW status still being under review.
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Illustrative
What surveyors actually found near you
We read the 82 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ogden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison Pointe Healthcare And Rehabilitation | 0.3 mi | ★★★★★ | 5 | 0 |
| Stonehenge Of Ogden | 1.5 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
| The Terrace Transitional | 2.3 mi | ★★★★★ | 0 | 0 |
| South Ogden Post-acute (cascades At South Ogden) | 2.4 mi | ★★★★★ | 14 | 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.