Inspection Reports for Crestwood Rehabilitation and Nursing
3665 Brinker Ave, Ogden, UT 84403, United States, UT, 84403
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Crestwood Rehabilitation and Nursing facility.
Findings
The facility was found deficient in ensuring adequate supervision to prevent resident elopement, providing palatable and properly heated food, and supplying drinks consistent with resident needs and preferences. Specific incidents included a resident eloping due to staff failure to respond to wander guard alarms, multiple residents complaining about cold and unappetizing food, and a policy restricting beverages other than water between meals causing resident dissatisfaction.
Deficiencies (3)
Failure to ensure adequate supervision to prevent accidents, resulting in a high-risk resident eloping from the facility due to staff turning off wander guard alarm and not redirecting or notifying others.
Failure to provide food that was palatable, attractive, and at a safe and appetizing temperature, with residents reporting cold and unappetizing meals.
Failure to provide drinks consistent with resident needs and preferences and sufficient to maintain hydration, including restricting beverages other than water between meals.
Report Facts
Sampled residents: 19
Residents affected by supervision deficiency: 1
Residents affected by food quality deficiency: 3
Residents affected by hydration deficiency: Some
Test tray temperatures (°F): 97.5
Test tray temperatures (°F): 98.6
Test tray temperatures (°F): 94.1
Test tray temperatures (°F): 63.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Provided detailed account of resident elopement and wander guard alarm protocol |
| Administrator | Administrator | Provided information on wander guard alarm system and staff education after elopement |
| Dietary Supervisor | Dietary Supervisor | Provided information on food service practices and beverage policy |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 1, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, and failure to properly plan resident discharge, including failure to timely report investigations to the State Survey Agency and delays in submitting New Choice Waiver (NCW) applications.
Complaint Details
The complaint investigation was substantiated for failure to report abuse and neglect investigations timely and inadequate investigation of abuse and neglect allegations involving residents 1 and 2. The facility also failed to ensure proper discharge planning and timely submission of NCW application for resident 6.
Findings
The facility failed to report the results of all abuse and neglect investigations to the State Survey Agency within required timeframes, inadequately investigated allegations involving two residents, and did not ensure timely discharge planning and submission of NCW applications for a resident desiring to return to the community.
Deficiencies (3)
Failure to report results of all investigations of abuse, neglect, exploitation, or mistreatment to the State Survey Agency within 5 days.
Failure to thoroughly investigate allegations of abuse from misappropriation of funds and neglect from a fall with serious injury for 2 residents.
Failure to ensure discharge needs were identified, discharge plans updated regularly, and referrals documented, resulting in a year-long delay in submitting NCW application for a resident.
Report Facts
Residents sampled: 7
Residents affected: 3
Days to submit 359 form: 5
Days to submit 358 form: 2
Percentage vertebral body height loss: 20
BIMS score: 10
Care conferences per year: 4
NCW application delay: 365
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Interviewed regarding failure to submit 359 form and investigation process |
| Resident Advocate | Resident Advocate (RA) | Interviewed regarding reporting abuse, NCW application delays, and care conferences |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Interviewed about reporting falls and abuse suspicions |
| CNA 1 | Certified Nursing Assistant (CNA) | Interviewed about fall incident and knowledge of abuse coordinator |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 29, 2024
Visit Reason
The inspection was a routine survey of Crestwood Rehabilitation and Nursing to assess compliance with regulatory requirements related to resident rights, care, treatment, abuse prevention, transfers, medication administration, nutrition, laboratory services, and record keeping.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, failure to notify physicians of critical blood sugar levels, inadequate evaluation of residents' capacity to consent to relationships, incomplete documentation and communication during resident transfers, medication errors, delayed feeding assistance, failure to provide timely hospital transfers upon resident request, inadequate supervision to prevent accidents, missing laboratory tests and reports, and improper handling of confidential resident information.
Deficiencies (12)
Residents sitting at the same table in the dining room were not served meals at the same time and food was served in disposable cups.
Facility did not notify the Medical Director when blood sugar results were outside of physician ordered parameters for notification for one resident.
Facility did not ensure residents remained free from abuse, neglect, and misappropriation of property related to capacity to consent to intimate relationships for two residents.
Facility did not document or communicate adequately during resident transfers for two residents.
Licensed Practical Nurse was observed to attempt to change physician medication orders without direction from the medical provider for two residents.
Resident waited 35 minutes to be fed by staff after meal was served.
Facility did not provide care to a resident who sustained a head laceration after a fall and requested hospital transfer via ambulance.
Facility did not provide adequate supervision to prevent accidents; a resident was found yelling for help in a staff bathroom without a call light.
Medication error rate exceeded 5 percent; residents were administered incorrect multivitamin and fiber supplement dosages.
Facility did not provide or obtain laboratory services/tests as ordered for three residents.
Facility did not keep signed and dated reports of x-rays and other diagnostic services in the resident's record for one resident.
Facility did not keep confidential information contained in the resident's medical record; a resident's name was used in another resident's medical record.
Report Facts
Medication error rate: 6.45
Residents sampled: 33
Residents affected: 9
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed modifying medication orders without physician direction |
| LPN 3 | Licensed Practical Nurse | Observed and interviewed regarding hospital transfer refusal and medication administration |
| RN 2 | Registered Nurse | Interviewed regarding transfer notification and documentation |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, transfers, lab services, and confidentiality |
| CRN | Corporate Resource Nurse | Interviewed regarding medication errors and transfer procedures |
| DA 1 | Dietary Aide | Interviewed regarding use of disposable cups for desserts |
| DM | Dietary Manager | Interviewed regarding use of disposable cups for desserts |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding blood sugar notification procedures |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding capacity to consent assessments and hospital transfer |
| Resident Advocate | Resident Advocate | Interviewed regarding capacity to consent assessments and resident relationships |
| Acting Administrator | Acting Administrator | Interviewed regarding resident 55's sex offender status and bathroom call light alarm |
| DOT | Director of Therapy | Observed responding to resident 51's calls for help in staff bathroom |
| DOM | Director of Maintenance | Interviewed regarding bathroom call light system |
| RN 1 | Registered Nurse | Interviewed regarding bathroom call light system and staff bathroom use |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding feeding assistance for resident 13 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report suspected abuse to Adult Protective Services (APS) involving three residents.
Complaint Details
The complaint investigation revealed that for three residents (IDs 2, 7, and 8), the facility did not report suspected abuse to Adult Protective Services. Resident 8 exhibited sexually explicit behavior towards resident 7, and an altercation between residents 2 and 5 resulted in police custody of resident 5. The facility notified the police and the State Agency but failed to notify APS as required.
Findings
The facility failed to report suspected abuse to APS for three residents despite notifying other authorities such as the police and the State Agency. Incidents included sexually explicit behavior by one resident towards another and an altercation resulting in police custody, with APS not being contacted as required by policy.
Deficiencies (1)
Failure to timely report suspected abuse to Adult Protective Services as required by facility policy and state law.
Report Facts
Residents sampled: 11
Residents affected: 3
Incident date: May 18, 2023
Incident time: 1425
Incident date: May 18, 2023
Incident time: 2153
Inspection Report
Routine
Deficiencies: 16
Date: Apr 18, 2022
Visit Reason
Routine inspection of Crestwood Rehabilitation and Nursing facility to assess compliance with regulatory requirements including medication administration, resident care, infection control, dietary services, and facility safety.
Findings
The inspection identified multiple deficiencies including failure to ensure resident self-administration of medications was clinically appropriate, breaches in resident medical record confidentiality, inaccurate resident assessments especially dental status, incomplete care plans, inadequate supervision of residents during smoking, failure to maintain continence programs, improper respiratory care, medication administration issues including unavailable medications, expired medication administration, inadequate menu planning and food service, poor infection control practices leading to COVID-19 exposure, failure to notify families of COVID-19 infections timely, and inadequate facility ventilation with strong odors throughout.
Deficiencies (16)
Facility did not ensure interdisciplinary team determined resident's right to self-administer medications was clinically appropriate for 1 of 34 residents.
Facility did not ensure resident medical records were secure and confidential; computer screens left unattended displaying personal information for 6 residents.
Facility did not ensure accurate assessments for residents dental status resulting in unmet dental needs for 2 residents.
Facility did not develop and implement comprehensive person-centered care plans for 4 residents including pressure sores, dental needs, and bowel/bladder programs.
Facility failed to ensure adequate supervision to prevent accidents; a resident was observed smoking unsupervised with dropped cigarette ash on lap.
Facility did not ensure residents continent of bladder and bowel received services to maintain continence; resident not assessed for bowel and bladder retraining.
Facility did not offer therapeutic fortified diets as ordered for a resident with nutritional problems.
Facility staff did not change oxygen tubing and humidifier bottles per physician's order for 3 residents.
Resident's medications were not administered as ordered due to unavailability by pharmacy; resident missed multiple doses of inhaler medication.
Facility administered expired medication to a resident.
Resident was administered medication outside physician ordered blood pressure parameters.
Facility menus were not prepared in advance, followed, or reviewed by dietitian; menu items changed without notification and portion sizes inconsistent.
Facility did not distribute and serve food in accordance with professional food safety standards; food items undated or past use-by date, refrigerator/freezer logs incomplete, cracked tiles in dish machine area.
Facility failed to establish infection prevention and control program to prevent COVID-19 spread; staff and visitors not properly screened, symptomatic staff worked, inadequate PPE use, resulting in COVID-19 exposure to residents.
Facility failed to notify residents and families timely of confirmed COVID-19 infections.
Facility did not have adequate outside ventilation by window or mechanical means; strong odors of urine and feces throughout facility.
Report Facts
Residents sampled: 34
Residents affected: 1
Residents affected: 6
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Visitors without screening forms: 30
Visitors without log signatures: 27
Visitors on 4/19/22: 13
Visitor screening questionnaires on 4/19/22: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Symptomatic staff member who tested positive for COVID-19 and worked while symptomatic |
| LPN 1 | Licensed Practical Nurse | Observed touching medications with bare hands and not performing hand hygiene during medication pass |
| ADON | Assistant Director of Nursing | Interviewed regarding medication delivery and infection control practices |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding smoking supervision and oxygen equipment maintenance |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding oxygen equipment maintenance |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding COVID-19 screening and testing |
| Administrator | Facility Administrator | Interviewed regarding COVID-19 outbreak and infection control |
| RNC | Regional Nurse Consultant | Interviewed regarding medication administration and infection control |
| LPN 3 | Licensed Practical Nurse | Employee with missing COVID-19 screening documentation |
| CNA 10 | Certified Nursing Assistant | Employee with missing COVID-19 screening documentation |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding dental assessments and care plans |
| CNA Supervisor | Certified Nursing Assistant Supervisor | Interviewed regarding COVID-19 screening process |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding oxygen equipment maintenance |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 4, 2021
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident assessments, medication management, staffing qualifications, and food service safety.
Findings
The facility was found deficient in multiple areas including failure to provide timely and accurate Minimum Data Set (MDS) assessments, failure to ensure gradual dose reductions for psychotropic medications, lack of full-time qualified dietary staff, and improper food storage and labeling practices.
Deficiencies (7)
Failure to inform residents of Medicaid/Medicare coverage and potential liability for services not covered, specifically failure to issue a Notice of Medicare Non-coverage (NOMNC) when Medicare Part A services were terminated for one resident.
Failure to conduct initial and periodic comprehensive, accurate, standardized reproducible Minimum Data Set (MDS) assessments of residents' functional capacity, including overdue annual and admission assessments for multiple residents.
Failure to update each resident’s assessment at least once every 3 months, with many quarterly MDS assessments incomplete or submitted late.
Failure to encode and transmit MDS assessment data to the State within required timeframes, including incomplete discharge assessments and late transmissions for multiple residents.
Failure to implement gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications, with no GDR attempted for over 12 months for one resident without documented clinical contraindications.
Failure to employ a full-time qualified Registered Dietitian or a certified dietary manager as director of food and nutrition services.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled and undated food items, improper storage of items requiring refrigeration, inability of dietary aide to test sanitizer concentration, and unlabeled beverages served during meal service.
Report Facts
Sampled residents: 45
Residents affected: 1
Residents affected: 7
Residents affected: 23
Residents affected: 14
Psychotropic drugs reviewed: 3
Psychotropic drug review meetings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic drug review meetings and GDRs |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed regarding MDS assessments and psychotropic drug review meetings |
| MDS Coordinator | Licensed Practical Nurse, MDS Coordinator | Interviewed regarding MDS assessments and training |
| Dietary Manager | Dietary Manager | Interviewed regarding certification and food service deficiencies |
| Dietary Aide 1 | Dietary Aide | Unable to demonstrate sanitizer testing and reported not labeling beverages |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding food storage procedures |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Observed serving beverages uncovered and unaware of covering requirements |
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