Crestwood Rehab: Grievance Left Unresolved for Weeks - UT
That finding sits at the center of a complaint inspection completed April 27, 2026, at the facility. Federal inspectors cited Crestwood for failing to resolve the grievance, track it through to a conclusion, and document whether the complaint was confirmed or not. The resident affected was identified only as Resident 1.
She had been living at the facility with a list of diagnoses that would make any bad day harder: type II diabetes, hypertension, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. When inspectors sat down with her on April 19, she told them what had happened in plain terms.
A CNA on the night shift let the door to the smoking area swing open and then walked away. When Resident 1 reached out to stop it from closing on her, it cut her finger and made it bleed. Nursing staff applied Neosporin and a bandage. She didn't know the CNA's name, only that she worked nights. "No one should be treating the residents that way," she told inspectors.
She had filed a grievance with the facility's Resident Advocate on April 10.
The form she filled out documented the concern this way: the CNA on the night shift did not hold the smoking door open for her and another resident, swinging it open and walking away. The form noted, after an initial review, that an allegation of abuse or neglect had not been identified.
After that, the form was essentially blank.
There was no documentation of any steps taken to investigate. No summary of findings. No conclusion. No written decision date. No signature from the resident. No signature from a grievance officer. No signature from the administrator. The back of the form, where the investigation details were supposed to go, had nothing on it.
Inspectors interviewed the Resident Advocate on April 22. Her account of what happened differed in a key detail from the resident's. The RA said Resident 1 had told her that when she went to stop the door from closing, a pre-existing cut on her finger reopened. Not that the door was slammed on her. The RA said Resident 1 did not claim the CNA acted intentionally or directed the behavior at her on purpose. She also said Resident 1 mentioned that the CNA seemed to be in a hurry.
The RA confirmed she had reported the incident to the administrator and the Director of Nursing.
That confirmation created its own problem.
When inspectors interviewed the administrator, the Director of Nursing, and a Regional Nurse Consultant together that same afternoon, both the administrator and the DON said they had not been informed about the incident with Resident 1. The administrator said she would open an investigation, pull the camera footage, and get statements from both the resident and the employee. The DON said she would assess Resident 1 for pain and injury.
It was April 22. The grievance had been filed April 10.
The administrator acknowledged the timeline herself. She told inspectors that if the form indicated no allegation of abuse, the grievance should have been resolved within a couple of days of submission. With the grievance having been initiated on April 10, she said, it should have been resolved by now.
The Regional Nurse Consultant offered a narrower explanation. She pointed to the blank back of the form and said it indicated the grievance was still in progress.
Still in progress, twelve days after a resident bled and asked for someone to look into it.
The gap between what the Resident Advocate said she reported and what the administrator and DON said they knew is not resolved anywhere in the inspection record. The RA said she told them. They said she didn't. Inspectors didn't adjudicate that contradiction — their citation focused on the grievance process itself, not on who knew what or when. But the contradiction sits there in the record.
What is clear is this: Resident 1 filed a formal grievance. The form was started and not finished. The investigation the form was supposed to trigger never began, at least not before inspectors arrived and asked about it. The resident, who had anxiety disorder and PTSD among her diagnoses, was left waiting for nearly two weeks with no word on whether anyone had looked at the camera, spoken to the CNA, or reached any conclusion at all about what happened to her finger.
The facility received a deficiency rating of minimal harm or potential for actual harm, the lowest tier on the federal harm scale. One resident was affected.
Those classifications can obscure what the experience actually feels like from inside a nursing home room. A resident in a facility does not have the option to follow up with a supervisor, escalate to HR, or walk away. She filed the form the facility gave her, with the person the facility designated to receive it, and then she waited. The system is supposed to close that loop. At Crestwood, for this resident, in April 2026, it did not.
When inspectors asked her about it on April 19, she still didn't know the name of the CNA who had been on the other side of that door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestwood Rehabilitation and Nursing from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Crestwood Rehabilitation and Nursing in Ogden, UT was cited for violations during a health inspection on April 27, 2026.
That finding sits at the center of a complaint inspection completed April 27, 2026, at the facility.
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.