Crestmoor Care Center: Grievance Process Failures - CO
The inspection, completed February 6, 2025, at the facility on South Monaco Parkway found a single deficiency rated at the lowest level of harm. But the details behind that finding stretch back not weeks, not months, but years.
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See the Derila PillowThe resident, identified in inspection records as Resident #24, filed a grievance on January 29, 2025, documenting that two pairs of pants were missing from his room. The social services director searched his closet and found nothing. His most recent inventory sheet listed four pairs of pants. The facility's proposed resolution was to purchase four new pairs as replacements.
The grievance form was signed by the resident and the nursing home administrator on February 3, during the survey itself. There was no date recorded for when the administrator had signed it.
The facility's own grievance process called for a resolution to be reached with the resident within 72 hours of the date a grievance was filed. The January 29 filing and the February 3 signature represent a gap of five days. The missing date on the administrator's signature made it impossible to determine when, exactly, he had reviewed it.
The nursing home administrator, interviewed by inspectors on February 6, offered context that reframed the missing pants as something far older than a January complaint. He said Resident #24 had a pattern of asking the facility to replace his pants going back to 2017. He said the resident had multiple inventory lists on file, and it had been unclear which list the facility was working from at any given time. He said the grievance process for the missing pants had actually begun in September 2024.
That would make the timeline roughly five months, not five days.
The administrator said the facility had not been successful in finding the missing pants and had not come to a successful resolution with the resident during that stretch. He said the issue came up again recently, and this time they were able to resolve it. Four new pairs of pants would be purchased.
The social services consultant, interviewed earlier the same day, described a process that sounded straightforward on paper. Grievance forms were kept at the front of the building. Residents or staff could fill them out, and submissions could be made anonymously. Social services would initiate the process and forward the concern to the appropriate department. Grievances were discussed in morning meetings. A resolution, she said, should be reached within 72 hours.
What the inspection record does not show is that process working as described for Resident #24.
The deficiency was tagged at the lowest severity level, meaning inspectors found minimal harm or potential for minimal harm, and it affected only a few residents. No fines were reported in connection with the finding. The facility's plan of correction was not included in the inspection document.
What the record does show is a man who had been raising the same concern, in some form, since at least 2017. A facility that acknowledged, through its own administrator, that it had gone months without resolving his complaint. A grievance form that arrived at a signature only once inspectors were already in the building reviewing it.
Resident #24 will receive four new pairs of pants. Whether the inventory sheet that started this, the one listing four pairs in his closet that nobody could locate, will be reconciled with whatever other lists exist in his file, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestmoor Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
CRESTMOOR CARE CENTER in DENVER, CO was cited for violations during a health inspection on February 6, 2025.
The inspection, completed February 6, 2025, at the facility on South Monaco Parkway found a single deficiency rated at the lowest level of harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.