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 nursing home care.
Findings
The facility was found deficient in providing adequate supervision to prevent resident elopement, ensuring food was palatable and served at safe temperatures, and providing sufficient drinks consistent with resident needs and preferences.
Deficiencies (3)
F 0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in a high-risk resident eloping due to staff turning off the wander guard alarm and not redirecting or notifying others.
F 0804: The facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature, with residents reporting cold and unappetizing meals and complaints documented in resident council meetings.
F 0807: The facility did not provide drinks consistent with resident needs and preferences, restricting beverages other than water between meals, which led to resident complaints.
Report Facts
Sampled residents: 19
Residents affected: 1
Residents affected: 3
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA 1) | Provided detailed interview about resident elopement and wander guard alarm procedures | |
| Administrator (ADM) | Provided interview regarding elopement incident and staff education | |
| Dietary Supervisor (DS) | Provided interview regarding food service procedures and beverage policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 1, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, and failure to properly plan discharge for residents at Crestwood Rehabilitation and Nursing.
Complaint Details
The complaint investigation was substantiated as the facility failed to timely report abuse and neglect investigations to the State Survey Agency and did not properly manage discharge planning and NCW application submissions for a resident.
Findings
The facility failed to report all investigation results to the State Survey Agency within required timeframes for two residents involved in abuse and neglect allegations. Additionally, the facility did not ensure proper discharge planning and timely submission of New Choice Waiver (NCW) applications for one resident.
Deficiencies (2)
F 0610: The facility failed to report the results of all investigations of alleged abuse and neglect to the State Survey Agency within 5 days. Specifically, investigations for two residents involving misappropriation of funds and a fall with serious injury were incomplete or delayed.
F 0660: The facility did not ensure that discharge needs were identified, discharge plans were regularly re-evaluated, and referrals to local agencies were documented. A resident's New Choice Waiver application was delayed for a year due to paperwork submission issues.
Report Facts
Residents sampled: 7
Residents affected: 2
Residents affected: 1
Vertebral body height loss: 20
BIMS score: 10
Inspection Report
Routine
Deficiencies: 13
Date: Jan 29, 2024
Visit Reason
Routine inspection of Crestwood Rehabilitation and Nursing facility to assess compliance with regulatory standards and resident care.
Findings
The inspection identified multiple deficiencies including failure to treat residents with dignity during dining, failure to notify physicians of critical lab values, inadequate assessment of residents' capacity for intimate relationships, incomplete documentation of resident transfers, medication administration errors, delayed feeding assistance, failure to provide timely hospital transfer upon resident request, inadequate supervision leading to resident safety risks, medication error rates above 5%, missing laboratory tests and results, and breaches of resident confidentiality.
Deficiencies (13)
F0550: Residents sitting at the same dining table were not served meals simultaneously and food was served in disposable cups, compromising dignity and quality of life.
F0580: Facility failed to notify the Medical Director of elevated blood sugar levels above 400 for a diabetic resident as required by protocol.
F0600: Facility did not ensure residents in a relationship had capacity to consent; assessments were incomplete and interdisciplinary review was lacking.
F0622: Facility failed to document resident transfers and did not provide required information to receiving providers for safe transitions of care.
F0658: Licensed Practical Nurse modified medication orders without physician direction, including changing multivitamin orders and dosage without approval.
F0677: Resident dependent on staff for feeding waited 35 minutes after meal was served before receiving assistance.
F0684: Facility failed to provide timely hospital transfer and care to a resident with a head laceration after a fall, delaying emergency treatment.
F0689: Resident was found calling for help in a staff-only bathroom without effective call light notification, indicating inadequate supervision and accident prevention.
F0759: Medication error rate exceeded 5%, including administration of incorrect multivitamin and fiber supplement dosage without proper orders.
F0770: Facility failed to obtain ordered laboratory tests for multiple residents, including CBC, CMP, TSH, iron levels, and lipid panels.
F0775: Laboratory reports for iron level, CBC, CMP, Hemoglobin A1c, and lipid panel were obtained but not filed in residents' medical records.
F0779: Facility did not file signed and dated chest x-ray results in resident's medical record, compromising documentation standards.
F0842: Resident names were improperly used in other residents' medical records, breaching confidentiality and privacy standards.
Report Facts
Medication error rate: 6.45
Residents sampled: 33
Residents affected by dignity deficiency: 9
Residents affected by blood sugar notification deficiency: 1
Residents affected by consent capacity deficiency: 2
Residents affected by transfer documentation deficiency: 2
Residents affected by medication order modification: 2
Residents affected by feeding delay: 1
Residents affected by hospital transfer delay: 1
Residents affected by supervision deficiency: 1
Residents affected by missing labs: 3
Residents affected by missing lab reports: 2
Residents affected by missing diagnostic reports: 1
Residents affected by confidentiality breach: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed modifying medication orders without physician approval and involved in resident 35 fall incident |
| LPN 3 | Licensed Practical Nurse | Witnessed resident 35 fall and hospital transfer delay, conflicted about ambulance call refusal |
| RN 2 | Registered Nurse | Described hospital transfer procedures and documentation |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding deficiencies, policies, and incidents |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed regarding blood sugar notification and hospital transfer procedures |
| Director of Maintenance | Director of Maintenance | Interviewed about bathroom call light system |
| Director of Therapy | Director of Therapy | Responded to resident trapped in staff bathroom |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Described feeding assistance practices for resident 13 |
| Resident Advocate | Resident Advocate | Interviewed about sexual capacity assessments and resident relationships |
| Acting Administrator | Acting Administrator | Interviewed about resident 55 sexual history and bathroom call light system |
| Dietary Aide 1 | Dietary Aide | Interviewed about use of disposable cups for desserts |
| Dietary Manager | Dietary Manager | Interviewed about dessert serving practices |
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 incidents involving residents to Adult Protective Services as required by law.
Complaint Details
The complaint investigation found that for 3 residents, the facility did not notify Adult Protective Services after suspected abuse incidents. The incidents included sexually explicit behavior by resident 8 toward resident 7 and a physical altercation where resident 5 was taken into police custody. The facility notified law enforcement and the State Agency but failed to notify APS as required.
Findings
The facility failed to report suspected abuse to Adult Protective Services for 3 of 11 sampled residents. Incidents included sexually explicit behavior by one resident toward another and an altercation resulting in police involvement, but APS was not notified as required.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse to Adult Protective Services for 3 residents after incidents involving sexual misconduct and physical altercation were reported to law enforcement and the State Agency but not APS.
Report Facts
Residents sampled: 11
Residents affected: 3
Brief Interview of Mental Status (BIMS) score: 13
Brief Interview of Mental Status (BIMS) score: 15
Brief Interview of Mental Status (BIMS) score: 15
Inspection Report
Deficiencies: 16
Date: Apr 25, 2022
Visit Reason
The inspection was conducted to investigate compliance with regulatory requirements including medication administration, resident care, infection control, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including medication administration errors due to unavailable medications, inadequate infection prevention and control practices resulting in COVID-19 exposure, failure to provide needed dental services, improper food service and menu management, unsafe respiratory care, inadequate staff and visitor COVID-19 screening, and poor environmental conditions including odors and ventilation issues.
Deficiencies (16)
F0554: The facility did not ensure that the interdisciplinary team determined if a resident's right to self-administer medications was clinically appropriate. One resident self-administered medication without evaluation.
F0583: The facility did not ensure residents' medical records were kept private and confidential. Computer screens with resident information were left unattended and visible.
F0641: The facility did not ensure accurate assessments for residents' dental status, resulting in unmet dental needs for two residents.
F0656: The facility did not develop and implement comprehensive person-centered care plans for residents, including for pressure sores, dental needs, and bowel and bladder programs.
F0689: The facility did not ensure adequate supervision to prevent accidents. One resident was observed smoking unsupervised with dropped ashes on his lap.
F0690: The facility did not assess a resident for possible bowel and bladder retraining despite frequent incontinence and resident desire to stop using briefs.
F0692: The facility did not provide a therapeutic fortified diet as ordered for a resident with nutritional problems; staff stated fortified diets were not provided at lunch.
F0695: The facility did not ensure respiratory care equipment such as oxygen tubing and humidifier bottles were changed and labeled weekly as ordered for three residents.
F0755: The facility did not provide routine and emergency drugs as ordered. One resident did not receive AirDuo inhaler medication due to pharmacy delivery delays, resulting in multiple missed doses.
F0757: The facility administered a medication to a resident after its expiration date was reached.
F0791: The facility did not provide needed dental services for residents with dentures that did not fit and residents with missing teeth experiencing mouth pain.
F0803: The facility menus were not prepared in advance, followed, or reviewed by the dietitian. Menu substitutions were made without notification and portion sizes served did not match the menu.
F0812: The facility did not distribute and serve food in accordance with professional food safety standards. Food items in refrigerators and freezers were not dated or past use-by dates, logs were incomplete, and there were cracked tiles and unsanitary conditions in the dish machine area.
F0867: The facility failed to establish an infection prevention and control program to prevent COVID-19 transmission. Staff and visitors were not properly screened, PPE was not used appropriately, and staff handled medications without hand hygiene. This resulted in three residents exposed to COVID-19.
F0880: The facility failed to ensure staff and visitors were screened for COVID-19 prior to entry, failed to implement PPE use during an outbreak, and failed to notify residents and families timely of COVID-19 infections.
F0923: The facility did not have adequate outside ventilation by window or mechanical means. Strong odors of urine and feces were noted throughout the facility including dining areas, hallways, and elevators.
Report Facts
Missed medication administrations: 9
Missed medication administrations: 12
Missed medication administrations: 2
Resident sample size: 34
Visitor screening non-compliance: 30
Visitor screening non-compliance: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Worked while symptomatic and tested positive for COVID-19, failed to screen properly |
| LPN 1 | Licensed Practical Nurse | Observed touching medications with bare hands without hand hygiene |
| Assistant Director of Nursing | ADON | Observed touching medications with bare hands without hand hygiene |
| LPN 2 | Licensed Practical Nurse | Interviewed about smoking supervision and medication administration |
| Dietary Manager | Dietary Manager | Interviewed about menu changes and food fortification |
| Regional Nurse Consultant | RNC | Interviewed about medication administration and infection control |
| Licensed Practical Nurse 1 | LPN | Interviewed about medication administration and resident assessments |
| Resident Advocate | RA | Interviewed about COVID-19 family notifications and dental appointments |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 4, 2021
Visit Reason
Routine inspection of Crestwood Rehabilitation and Nursing to assess compliance with Medicare and Medicaid regulations, including resident assessments, medication management, staffing, and food service.
Findings
The facility had multiple deficiencies including failure to provide timely and complete Minimum Data Set (MDS) assessments and transmissions, lack of gradual dose reductions for psychotropic medications without clinical contraindications, insufficient qualified dietary staff, and improper food storage and labeling practices.
Deficiencies (7)
F0582: Facility did not inform a resident of Medicaid/Medicare coverage and potential liability for services not covered, failing to issue a Notice of Medicare Non-coverage when Medicare Part A services were terminated.
F0636: Facility failed to conduct initial and periodic comprehensive Minimum Data Set (MDS) assessments timely for multiple residents, with many annual MDS assessments incomplete or in progress beyond required timeframes.
F0638: Facility did not update residents' assessments at least once every 3 months, with 23 of 45 sampled residents having overdue or incomplete quarterly MDS assessments.
F0640: Facility failed to encode and transmit MDS assessment data to the State within required timeframes, with 14 of 45 residents' assessments transmitted late or incomplete.
F0758: Facility did not ensure gradual dose reductions (GDR) of psychotropic drugs unless clinically contraindicated; one resident had no GDR attempted for over 12 months without documented contraindications.
F0801: Facility did not employ a full-time qualified Registered Dietitian or a certified dietary manager as director of food and nutrition services.
F0812: Facility failed to store, prepare, distribute, and serve food in accordance with professional standards; food items were unlabeled or undated, opened refrigerated items stored improperly, sanitizer testing was inadequate, and beverages served were left open and unlabeled.
Report Facts
Sampled residents: 45
Residents affected by MDS assessment deficiencies: 23
Residents affected by MDS transmission deficiencies: 14
Psychotropic drug review meetings: 5
Psychotropic drugs prescribed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Advocate | Interviewed regarding notification of Medicare non-coverage for resident 6 | |
| MDS Coordinator | Interviewed regarding overdue MDS assessments and training | |
| Corporate Resource Nurse | Interviewed regarding MDS assessment accuracy and transmission | |
| Director of Nursing | Interviewed regarding psychotropic drug review meetings and GDR documentation | |
| Dietary Manager | Interviewed regarding certification status and food service deficiencies | |
| Licensed Practical Nurse 1 | Interviewed regarding food storage and labeling procedures | |
| Dietary Aide 1 | Interviewed and observed regarding sanitizer testing and beverage preparation | |
| Certified Nursing Assistants | Observed serving beverages to residents |
Viewing
Loading inspection reports...
