Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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 paraplegia and other significant diagnoses sustained a buttock shearing injury during a Hoyer lift transfer when a CNA improperly removed the sling from under the resident. The resident reported that a newer sling had sharper edges and caused the cut, and the IDT determined the injury was related to friction and shearing from incorrect sling removal.
Pain management was not consistently provided for two residents with ongoing pain needs. One resident with chronic pain, spasticity, paraplegia, and wounds reported that pain meds were reduced after admission and that a requested pain clinic visit was not scheduled as expected, despite repeated complaints of discomfort and provider notes documenting active pain and a referral. Another resident reported severe thumb pain that disrupted sleep, but the MAR did not clearly show PRN pain meds were offered, refused, or given on key dates, and the follow-up pain assessment after acetaminophen was documented only minutes after administration.
Food service safety standards were not followed. Staff used the wrong sanitizer test strips for quat solution, did not know how to interpret the results, and were observed handling dirty dishes and clean dishes with the same gloves and placing dirty items on the clean side of the dishmachine. The dishmachine temperatures were repeatedly below required levels, logs were incomplete, and the kitchen and storage areas had soiled surfaces and improperly dated or undated food items.
A facility failed to ensure meals were palatable, attractive, and served at an appetizing temperature. Residents reported cold coffee and food, tough or overcooked meats, tasteless meals, poor portion sizes, and trays that did not match diet needs or preferences, including missed gluten-free and other ordered items. A test tray was also observed with unappealing, difficult-to-eat food, and resident council minutes and grievances documented repeated complaints about meal quality and tray accuracy.
A resident with chronic wounds and multiple comorbidities received wound care without EBP, with staff entering without gowns, failing to perform hand hygiene at key points, and cleansing wounds in a back-and-forth manner across the wound bed. The dressing was not labeled and dated, and the facility also repeatedly transported uncovered coffee through the hallways to resident rooms during meal service.
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.
Window Covered in Dryer Lint: A resident’s room window was observed covered in dryer lint and later was still completely obscured from the outside. The resident said general cleaning was being done but deep cleaning was not happening. HK staff said outside windows were not on the cleaning schedule, the HM had not cleaned them yet, and the dryer vent near the window had been broken for months.
A resident with paraplegia, PTSD, depression, anxiety disorder, and insomnia had a PRN Trazodone order for insomnia that continued beyond the 14-day limit without a documented physician rationale or duration in the medical record. The MAR showed repeated administrations of the PRN medication, including two doses within one 24-hour period, and the DON stated the psychotropic review noted GDR was contraindicated but did not document a rationale for the ongoing PRN order.
The facility failed to immediately report a suspected neglect event to the SSA for a resident who developed buttock skin breakdown during a staff-assisted Hoyer lift transfer. The resident had multiple serious diagnoses, including paraplegia and a prior lower leg fracture, and SN documented that the injury was related to the CNA removing the sling. The administrator was unsure whether the incident had been reported, and no documentation was found to confirm SSA reporting.
Failure to Provide Effective Discharge Planning: A resident with COPD, DM2, cerebral infarction, schizophrenia, and a history of TIA wanted to discharge to an apartment or assisted living, but the facility did not have a discharge planning care plan in the medical record. A Behavioral Complex Interdisciplinary Team Review noted PASSR-related discharge planning recommendations, while the Resident Advocate stated the resident did not have a discharge plan, wanted another LTC facility but those facilities were full, and had discussed assisted living and the New Choice Waiver with him.
A resident with paraplegia and other significant diagnoses sustained a shearing wound to the buttocks during a Hoyer lift transfer, but the wound care order and related documentation were not entered into the record until several days later. The DON and ADON stated verbal orders were obtained from the WCP and care was reportedly provided, yet the TAR and progress notes did not reflect the wound treatment when it occurred, and weekend staff would not have had notification of the order in the chart.
A resident with multiple medical problems, including stroke-related limitations, was monitored for expressions of sadness and depressive statements and became tearful when discussing loss of independence. Although staff documented some non-pharmacologic interventions and a psychotropic review noted sertraline use with an unclear indication, the record did not show documented behavioral health services or a clear psychosocial care plan. Interviews revealed conflicting accounts about whether mental health services had been provided, and no documentation of such services was found.
An unlocked medication cart was observed unattended outside resident rooms on the second floor. RN 1 confirmed he had left the cart unlocked and unattended, and the DON stated that when staff walk away from the medication cart and no other staff are present, it should be locked.
Ordered BMP Not Obtained: A resident with paraplegia, osteomyelitis, anemia, PTSD, depression, anxiety disorder, and insomnia had a provider-ordered BMP that was not obtained. No lab results were found in the chart, the DON and RNC were still searching for them, and the DON later stated the BMP was never drawn and there was no evidence the specimen had been collected.
A resident with paraplegia, osteomyelitis, anemia, PTSD, depression, anxiety disorder, and insomnia had a physician-ordered urinalysis, but the lab report was not found in the medical record. The DON later requested the results, and the RNC emailed the lab report, stating it had been sent to the provider but was not sure why it was not filed in the resident’s chart.
A resident with multiple diagnoses including dementia, atrial fibrillation, dysphagia, and chronic pain had a productive cough and bilateral crackles, and the MD ordered a STAT CXR after being notified. Record review found no signed and dated CXR report in the resident record. The DON stated the result was reviewed with the nurse and was located in a group chat, but it was not included in the medical record, and the facility needed to work on its weekend process.
Lack of Qualified Food Service Director: The facility did not have a full-time, designated director of food and nutrition services or a qualified food service director. The DM stated she had no certification and had been pulled to work in the kitchen due to low staffing, while the Administrator stated he did not know whether the DM was certified and said the RD worked only 1 day a week.
A resident with chronic pain, stage 4 pressure ulcers, paraplegia, and other serious diagnoses said his pain meds were decreased after admission and his requested pain clinic appointment was not scheduled for months, despite physician notes referring him to pain clinic. In addition, an RN left the med cart computer unlocked with resident records and the nurse report sheet visible to passersby, and the DON confirmed resident privacy should have been protected.
A resident with diagnoses including dementia, bipolar disorder, and pulmonary HTN had an inaccurate Wellbutrin XL order documented as 12 tablets daily instead of 1 tablet daily. In a separate event, an RN left the med cart unattended with the computer open to resident records and a nurse report sheet with resident medical information visible; the DON stated resident records should not be visible when staff walk away from the cart.
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 Prevent Shearing Injury During Hoyer Lift Transfer
Penalty
Summary
The facility did not ensure that a resident received adequate supervision and assistance devices to prevent accidents during Hoyer lift transfers. Resident 10 was admitted with diagnoses including unspecified fracture of the right lower leg, paraplegia, cirrhosis of the liver, rhabdomyolysis, and mild protein-calorie malnutrition. The resident stated that he was cut on the buttocks during a Hoyer lift transfer by a new sling that had sharper edges than his previous sling, and that the sling was replaced after the initial injury. He also stated that the wound had been painful. A nursing progress event note documented that during a weekly skin assessment, breakdown was found on the resident’s right buttock and was identified as a shearing injury related to the Hoyer sling being removed by a CNA. The interdisciplinary team determined that improper removal of the Hoyer sling from under the resident caused friction and shearing injury. Interviews with CNA staff indicated that two CNAs typically performed Hoyer transfers and removed the sling by gently rolling the resident side to side, and the DON stated that the injury was determined through interviews, assessment, and discussion with the WCP to have resulted from incorrect removal of the sling.
Pain management not consistently provided or documented for two residents
Penalty
Summary
Safe, appropriate pain management was not provided for two sampled residents whose pain required ongoing assessment and treatment. The deficiency involved one resident whose pain medications were decreased after admission and whose request for a pain clinic appointment was not documented as being scheduled for months, despite repeated reports of discomfort and a history of chronic pain, paraplegia, osteomyelitis, spasticity, and pressure ulcers. The resident stated he had asked for telehealth with the pain clinic and that the appointment was not arranged when requested. Facility interviews confirmed there was no documentation showing when the pain clinic appointment was scheduled after admission. The resident’s record showed multiple provider notes documenting chronic pain, opioid dependence, muscle spasms, and active discomfort. A physician note stated the resident wanted more opioids and that staff did not feel this was indicated, with a referral to pain clinic noted. Another note documented that he continued to report pain and wanted to see pain management and PM&R. The resident’s MAR showed he complained of pain higher than 6 on 21 occasions in April 2026. Facility leadership stated the former ADON knew about the pain clinic appointments, but there was nothing documented, and the DON acknowledged there was no documentation that the pain clinic appointment was scheduled after admission. A second resident reported pain in both thumbs that kept her awake at night, and her thumbs were observed to be red at the knuckles. Her record included orders for gabapentin, PRN acetaminophen, and pain monitoring every shift with documentation of interventions. The MAR documented pain scores of 10/10 on three dates, but the recorded interventions did not show that PRN pain medication was administered or refused on two of those dates, and the follow-up assessment after one acetaminophen dose was documented only 7 minutes after administration. Interviews with nursing staff and the DON/RNC indicated that documentation should have reflected whether PRN medication was offered, refused, or given, and that the resident’s pain reports, cognitive status, and non-pharmacological interventions should have been considered. The facility pain policy stated that staff should recognize pain, observe for nonverbal indicators, and use resident-specific pharmacological and non-pharmacological interventions.
Food Safety and Dishwashing Process Failures
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards. During a kitchen observation, the sanitizer buckets were being tested with chlorine strips even though the sanitizer in use was labeled quaternary sanitizer, and the dietary aide stated she did not know what color the strip should change to. An omelet was placed directly on the trayline counter and then picked up and placed on a tray with other omelets before being served. The drink refrigerator contained two cups of milk with no date, and the walk-in refrigerator contained multiple foods dated beyond 7 days, including ground meat dated 4/11/26, gravy dated 4/12/26, chicken drumsticks dated 4/12/26, sliced bologna dated 4/14/26, and four cups of fruit with no dates. The kitchen also had soiled areas, including a brown substance on pipes in dry storage, a black substance on the dry storage floor, and black and brown substances on the kitchen floor around the outside walls, electrical outlet, and equipment legs. On follow-up observation, the floor remained soiled around the outside walls, equipment legs, and electrical box, and a mop bucket with black water was next to the clean dish area. Staff were observed using sanitizer buckets without demonstrating knowledge of the test strip results, and one dietary aide stated he did not know what the color change meant and did not test the sanitizer every time he made the solution. The dish machine was not operating at the required temperatures during observation. The washing temperature was observed at 90 degrees Fahrenheit and the rinse temperature at 110 degrees Fahrenheit, while the log showed missing entries for several meals and indicated the wash cycle needed to be above 120 degrees Fahrenheit, the rinse above 75 degrees Fahrenheit, and sanitizer above 50 parts per million. During follow-up, the dish machine continued to show wash and rinse temperatures below the required level at multiple checks. Staff were observed using the same gloved hands to handle dirty dishes, remove clean dishes, and put away clean items, and dirty dish racks were placed on the clean side of the dishmachine and pushed into the machine with the same gloves.
Food Quality and Meal Service Deficiencies
Penalty
Summary
The facility did not ensure that food and drinks were palatable, attractive, and served at a safe and appetizing temperature for 12 of 40 sampled residents. Multiple residents reported that meals were cold, overcooked, undercooked, tough, tasteless, or otherwise unappealing. One resident stated the food and coffee were usually served cold and that the food tasted awful, while another said he could not chew the meat because it was too tough. Other residents described meals as terrible, obnoxious, or not good, and several said they routinely had to request alternative menus because the food offered did not meet their needs or preferences. Resident interviews also described problems with diet accuracy and meal adequacy. One resident said the kitchen did not follow her food preferences and continued to serve foods she could not eat, including potatoes, peas, carrots, and fruit despite her stated dietary restrictions. Another resident reported receiving two overcooked hotdogs with no condiments, bun, or side dishes, and said the portions were too small. A resident on a high-protein diet for wound healing reported receiving only two slices of bread with cheese that was not melted and a small amount of tomato soup. Another resident stated the food was not served warm and was microwaved, making the chicken rubbery. One resident who needed gluten-free food said she was not served gluten-free meals and had to spend her own money on food. Observation and record review supported the resident concerns. A test tray delivered to the 200 hallway contained pepperoni pizza, thin bread, and white cake; the pizza was 142 degrees Fahrenheit but was tough to chew and could not be cut, the garlic bread was very thin and crunchy, and the tray contained only brown and white foods with no color. Resident council minutes documented ongoing concerns about meal tickets, dislikes not being read, and complaints about cold coffee and food. Grievance records also showed repeated complaints about hard bread, meats that could not be chewed, disliked items on trays, old produce and undercooked chicken, and a lack of communication about the daily menu and tray contents.
Infection Control Lapses During Wound Care and Uncovered Drink Transport
Penalty
Summary
The facility did not maintain an infection prevention and control program that provided a safe, sanitary, and comfortable environment and helped prevent the development and transmission of communicable diseases and infections. For one sampled resident with diagnoses including type II diabetes mellitus, morbid obesity, peripheral vascular disease, lymphedema, and atopic dermatitis, the record showed ongoing wound care for wounds to the right foot and bilateral posterior thighs. The resident stated he had cellulitis on the right leg and an infection on the heel of his foot, and the record showed wound care orders for multiple wounds requiring regular dressing changes. During observed wound care, staff did not use Enhanced Barrier Precautions even though the resident had chronic wounds and the facility policy identified wound care as an indication for EBP. Two staff entered the room without gowns, and hand hygiene was not observed before glove use. During care of the right foot wound, gloves were not changed and hand hygiene was not performed between steps, and the wound was cleansed in a back-and-forth motion across the wound bed multiple times. During care of the thigh wounds, the wound bed was also cleansed by wiping multiple times over the same site in a back-and-forth motion. The dressing to the foot wound was not labeled and dated, and the thigh dressings were not secured in place. The report also documented repeated observations of uncovered drinks being transported through the facility. A CNA poured coffee into a mug and carried it uncovered down the hallway to a resident room, and additional observations showed uncovered cups of coffee being walked from the dining room or meal cart area to resident rooms. These events occurred while meal service was underway and drinks were delivered through the hallway without being covered during transport.
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.
Window Covered in Dryer Lint
Penalty
Summary
The facility did not provide a safe, clean, comfortable, and homelike environment for one sampled resident when the resident’s window was observed covered in dryer lint. On 4/19/26, resident 63’s room was observed and the window was covered in dryer lint. The resident stated that general cleaning was being done but deep cleaning was not happening, and said the window needed to be wiped down. On 4/27/26, the window was again observed and was completely obscured from view with little light penetrating because it was covered in dryer lint on the outside. Housekeeping staff stated the resident’s room had been deep cleaned on 4/20/26, but the outside of the windows was not on the cleaning schedule and the last time the outside dryer vent was cleaned was unknown. The Housekeeping Manager stated the outside windows were his responsibility but had not been cleaned yet, that the window was near the dryer vent, that the dryer vent had been broken since December 2025, and that ordering parts to fix the vent had not been done because it was not a priority.
PRN Psychotropic Order Exceeded Allowed Duration Without Documented Rationale
Penalty
Summary
The facility did not ensure that a PRN order for the psychotropic medication Trazodone was limited to 14 days unless the prescribing practitioner or attending physician documented a rationale in the resident’s medical record and indicated the duration for the PRN order. Resident 8 was admitted and later re-admitted with diagnoses including paraplegia, PTSD, depression, anxiety disorder, and insomnia. On 4/8/26, the physician ordered Trazodone HCL 150 mg by mouth every 24 hours as needed for insomnia, and the order was discontinued on 4/20/26 and reinstated the same day. Resident 8’s April MAR showed multiple administrations of the PRN Trazodone, including two doses on 4/19/26 within a 24-hour period even though the order was for one PRN dose in 24 hours. The resident’s psychotropic medication review dated 11/24/25 did not document ongoing use of the PRN Trazodone, and the medical record did not contain documentation of a physician rationale to extend the PRN order beyond 14 days with a duration of use. During an interview on 4/27/26, the DON stated that Trazodone was prescribed for insomnia and that the psychotropic review documented GDR was contraindicated, but did not document a rationale for the ongoing PRN Trazodone order.
Failure to Report Suspected Neglect Involving Resident Injury During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that allegations of neglect, including events that caused reasonable suspicion of neglect, were reported immediately to the State Survey Agency. For 1 of 40 sampled residents, Resident 10, the facility did not report a resident injury that occurred during a staff-assisted transfer with a mechanical lift. Resident 10 was admitted with diagnoses including unspecified fracture of the right lower leg, paraplegia, cirrhosis of the liver, rhabdomyolysis, and mild protein-calorie malnutrition. During a weekly skin assessment, skilled nursing staff noted skin breakdown on the resident’s buttocks and documented that the wound was related to a Hoyer sling being removed by a CNA. The nurse contacted the MD and wound NP for orders and to review interventions, but the administrator later stated he was unsure whether the incident had been reported to the SSA, and no documentation could be located to show that it was reported.
Failure to Provide Effective Discharge Planning
Penalty
Summary
The facility did not provide an effective discharge planning process for resident 52, who was admitted and later readmitted with diagnoses including COPD, type 2 diabetes mellitus, cerebral infarction, schizophrenia, and a history of transient ischemic attack. During an interview on 4/19/26, resident 52 stated he wanted to discharge to his own apartment or possibly assisted living, and said staff told him he did not make enough money for the New Choice Waiver even though he was on Medicaid. A Behavioral Complex Interdisciplinary Team Review dated 4/17/26 noted that the resident had recommendations for specialized services or PASSR discharge planning. However, there was no discharge planning care plan in the resident’s medical record. On 4/22/26, the Resident Advocate stated resident 52 did not have a discharge plan and was going to need LTC, that he wanted to discharge to another LTC facility but those facilities were full, and that she had discussed assisted living and the New Choice Waiver with him but was not sure about his income. The Resident Advocate also stated she documented the discharge plan in the progress notes and that the ADON completed discharge care plans.
Delayed documentation and wound care after shearing injury
Penalty
Summary
The facility did not ensure that Resident 10 received treatment and care in accordance with orders, the resident’s preferences and goals, and professional standards of practice after he sustained a shearing wound to the buttocks during a Hoyer lift transfer. Resident 10 was admitted with diagnoses including an unspecified fracture of the right lower leg, paraplegia, cirrhosis of the liver, rhabdomyolysis, and mild protein-calorie malnutrition. He reported that a new sling with sharper edges cut his buttocks during transfer, that the sling was later replaced, and that the wound was painful. A weekly skin assessment documented skin breakdown to the right buttock due to a shearing injury related to the Hoyer sling, and the nurse contacted management, the MD, and the wound NP for orders and interventions. The record showed that the wound-related progress notes were entered as late entries after the injury was discovered, and the wound care order was not documented until several days later. The facility did not document any treatment orders or wound care provided before the order was entered, despite the DON stating that verbal wound care orders had been received from the WCP and that care was provided that night. The DON also stated the incident should have been documented in the progress notes, and the ADON stated the order was not entered until the following Monday, meaning weekend staff would not have received notification to perform wound care if the order was not in the medical record. The WCP confirmed she gave an order for the wound, but the resident later refused wound assessments on multiple occasions.
Failure to Provide Behavioral Health Services for Resident With Depressive Statements
Penalty
Summary
The facility did not provide necessary behavioral health care and services for one resident who was monitored for depressive statements and tearful expressions about his loss of independence after a stroke. The resident was admitted with multiple diagnoses including ischemic cardiomyopathy, unsteadiness, muscle weakness, history of falls, severe protein-calorie malnutrition, cachexia, contractures of both hands, and need for assistance with personal care. During an interview, the resident became tearful several times while describing his physical limitations and stated that he did not currently have mental health services. The record showed repeated monitoring for expressions of sadness and depressive statements, with non-pharmacologic interventions documented on many shifts, but the baseline care plan did not include social services documentation or identified psychosocial needs/problems. The MDS admission assessment triggered Psychosocial Well-being, and a psychotropic review documented sertraline 50 mg daily with an unclear indication, noting the resident had verbalized sadness and that non-pharmacologic interventions included encouraging him to leave his room, interact with others, watch TV, visit with his roommate, and receive active listening. The sertraline dose was reduced and later discontinued, but no further psychotropic review occurred after discontinuation. Interviews showed conflicting information about behavioral health services. The Resident Advocate stated the resident had been seen by a local mental health company and had expressed feeling depressed, while the Regional Nurse Consultant stated he was not signed on with mental health services and had not voiced a desire for services. The RNC also stated the resident did not need to request services and that staff should inform the MD and RA when mental health services were needed, yet no documentation of mental health services could be found for the resident. Staff interviews confirmed the resident was monitored for depression-related behaviors, but the record did not show that behavioral health services were arranged or documented.
Unlocked and Unattended Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and accessible only to authorized personnel when a medication cart was observed unlocked and unattended outside resident rooms on the second floor between room [ROOM NUMBER] and 204. At approximately 8:10 AM, RN 1 was interviewed after being observed exiting room [ROOM NUMBER] and confirmed that he had left the medication cart unlocked and unattended. During a later interview, the DON stated that when staff walk away from the medication cart and no other staff are present, it should be locked.
Ordered BMP Not Obtained
Penalty
Summary
Provide timely, quality laboratory services/tests to meet the needs of residents was deficient because the facility did not obtain a Basic Metabolic Panel (BMP) that was ordered by the provider for Resident 8. Resident 8 was admitted and later re-admitted to the facility with diagnoses including paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 4/15/26, the physician ordered a BMP, but no laboratory results could be found in the resident’s medical record. During follow-up on 4/27/26, the DON was asked for the BMP results, the RNC stated by email that they were still looking for them, and later that day the DON stated the BMP was never drawn and there was no evidence that the laboratory specimen had been obtained. The DON also stated the phlebotomist believed it had been done, but the laboratory could not find the results.
Missing Laboratory Report in Resident Record
Penalty
Summary
Complete, dated laboratory records were not kept in the resident's clinical record for 1 of 40 residents sampled. Resident 8 was admitted and later re-admitted with diagnoses including paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 3/21/26, the physician ordered a urinalysis, but no documentation of the laboratory results could be found in the resident's medical record. On 4/27/26 at approximately 8:00 AM, the DON was asked to provide the urinalysis results, and at 8:40 AM the RNC emailed the laboratory results. At 9:40 AM, the DON stated the urinalysis results had been obtained from the laboratory, and the RNC stated she had a copy from the laboratory at one point because it was sent to the provider, but she was not sure why it did not make it into the resident's medical record.
Missing Chest X-Ray Report in Resident Record
Penalty
Summary
Keep signed and dated reports of x-rays and other diagnostic services in the resident record was not met for 1 of 40 sampled residents. Resident 6 was admitted and re-admitted with diagnoses including contracture of both hands, dysphagia, hypothyroidism, dementia, atrial fibrillation, pain, hypertension, chronic pain, deformity of the left lower leg, peripheral vascular disease, and idiopathic neuropathy. On 1/10/26, a progress note documented that the resident had a productive cough and bilateral crackles, the MD was notified, and a STAT chest x-ray was ordered. During record review, no documentation of the chest x-ray was found in the resident's medical record. The DON stated the results came in on Saturday and were reviewed by the MD with the nurse, that the result was located in a group chat, and that she did not know why it was not included in the resident's medical record. The DON also stated the facility needed to work on its weekend process.
Lack of Qualified Food Service Director
Penalty
Summary
The facility did not employ a full-time, designated person to serve as the director of food and nutrition services, and it did not have a qualified food service director. During interview, the Dietary Manager stated she did not have a certification and had been the DM for 3 years. She also stated the Registered Dietitian was at the facility weekly for the nutrition at risk meeting and was available by phone anytime, and that she had registered for the course a few times but was pulled back to work in the kitchen because staffing was low. The Administrator stated he did not know whether the DM had a certification and stated the RD worked 1 day a week at the facility.
Delayed Pain Clinic Referral and Unsecured Resident Records
Penalty
Summary
A resident with stage 4 pressure ulcers, paraplegia, osteomyelitis, spastic hemiplegia, and injury of the root of the cervical spine reported ongoing pain after admission and said the house physician decreased his pain medication. He stated he requested a pain clinic appointment because of the decreased pain medication and asked for a telehealth appointment, but it was never scheduled until much later, despite a physician note documenting that he wanted more opioids and would be referred to a pain clinic. The record also showed follow-up notes about chronic pain and referrals, but the facility had no documentation that the pain clinic appointment was scheduled after admission, and the DON acknowledged there was no documentation that it had been scheduled. During observation of the medication cart, the computer was unlocked and open to resident records, and the cart contained the nurse's resident roster and report sheet with medical information visible to passersby. RN 1 was observed leaving the area and confirmed the computer had been left open and unattended. The DON stated that when staff walk away from the medication cart, the MAR and nurse report sheet should not be visible when staff are not around, and that staff should always protect resident privacy.
Inaccurate medication order and exposed resident records
Penalty
Summary
Medical records were not accurately documented for one sampled resident. The resident was admitted with diagnoses including muscle weakness, altered mental status, dementia, bipolar disorder, and pulmonary hypertension. A physician order dated 2/27/25 and discontinued 3/4/25 listed Wellbutrin XL 150 mg extended-release oral tablet with directions to give 12 tablets by mouth one time a day for depressive symptoms. A nursing progress note dated 2/26/25 documented that the nurse received new orders and reviewed them with the facility NP, who discontinued Namenda and started Wellbutrin XL 150 mg orally daily due to increased depressive symptoms. During interview on 4/21/26, the Regional Nurse Consultant stated the Wellbutrin XL order should have been 1 tablet and not 12, and that the resident did not receive 12 tablets per day. Pharmacy orders provided by the RNC showed the resident received 30 tablets before reordering 30 days later. In a separate observation on 4/19/26, the medication cart on the second floor had the computer open to resident records and a nurse report sheet with resident medical information visible to passersby while the cart was unattended. RN 1 confirmed he had left the medication cart unattended with resident information visible, and the DON stated that resident medical records should not be visible when staff walk away from the medication cart.
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.
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 87 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
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 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 | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.