Crestwood Rehabilitation And Nursing

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had seen resident 1, and that was when they both heard the wander guard alarm go off upstairs. CNA 1 stated that the licensed nurse replied, oh there he is. CNA 1 stated that resident 1 liked to sit upstairs by the windows and the video games in the front of the building. CNA 1 stated that the licensed nurse had said it was okay for resident 1 to be upstairs. CNA 1 stated that neither she nor the licensed nurse went to check

on resident 1 when they heard the wander guard alarm sound. CNA 1 stated that they assumed that the staff upstairs had checked on resident 1. CNA 1 stated that later that day when they were retrieving the lunch trays they noticed that resident 1 had not eaten anything. CNA 1 stated that this was at approximately 12:30 PM. CNA 1 stated that was when they started looking for resident 1. CNA 1 stated that she searched all the rooms and bathrooms on the first floor and other staff searched the outside surrounding areas. CNA 1 stated that resident 1 came back to the facility a few hours later on his own. CNA 1 stated that the process for elopements was to have all staff clear the halls and check all rooms and hallways to verify if the resident was in the building. CNA 1 stated that if the resident was not located they notified the Director of Nursing and management. CNA 1 stated that if the alarm was sounding all staff should look for the resident who was setting off the alarm, verify their location, and then notify all staff over the walkie talkies that the alarm was cleared. CNA 1 stated that when resident 1 returned to the facility he was confused and had said

he was out looking for another resident at a construction site. On 12/30/25 at 10:25 AM, an interview was conducted with the Administrator (ADM). The ADM stated that resident 1 had a wander guard on him and prior to his elopement it was determined that he was not safe to access the community on his own. The ADM stated that a housekeeper was not aware that resident 1 could not exit the facility independently any longer and when the wander guard system alarmed on the day of resident 1's elopement she turned the alarm off. The ADM stated that education was provided to all staff about the wander guard system and what to do when the alarm sounded. The ADM stated that prior to resident 1's elopement nursing staff were aware of the wander guard alarm system and should have verified the location of all residents with wander guard when the alarm sounded. The ADM stated that nursing staff knew the wander guard protocol and should have responded to the alarm. The ADM stated that resident 1 was eventually found nearby at a bus station and was escorted back by facility staff. The ADM did not provide a timeline of the events or when the resident was found. Review of the facility policy for Elopements and Wandering Residents documented that

the facility was equipped with door locks and alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.

The policy was last revised on 4/30/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestwood Rehabilitation and Nursing

3665 Brinker Avenue Ogden, UT 84403

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review it was determined, for 3 of 19 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not attractive or palatable, and there were complaints in the resident council meetings. Resident identifiers: 2, 16, and 17. Findings include:On 12/29/25 at 11:51 AM, an interview was conducted with resident 17. Resident 17 stated the food tasted like shit. Resident 17 stated They could starve a bird with the food they serve here. Resident 17 stated he was served only a piece of toast and coffee for breakfast yesterday. On 12/29/25 at 1:39 PM, an

interview was conducted with resident 2. Resident 2 stated the food was served cold. On 12/30/25 at 11:07 AM, an interview was conducted with resident 16. Resident 16 stated the food was not good and she did not eat lunch on 12/29/25. Resident 16 stated it was popcorn chicken with all breading and it looked horrible. Resident 16 stated she did not eat anything for lunch. On 12/29/25 at 12:27 PM, an observation was made of the trayline during lunch. [NAME] 1 was observed to plate the food and then put a plate into a base. At 12:41 PM, [NAME] 1 was observed to use a hot pellet under a plate. [NAME] 1 stated they were out of bases. At 12:45 PM, the last tray was plated for the 200 hallway. At 12:48 PM, the meal cart was set outside the kitchen with resident meals and the test tray. At 12:58 PM, the last tray was served to residents and the test tray temperatures were obtained. The tray had brussel sprouts that were dark green/brown colored, popcorn chicken was brown, and the rice was white. There was a yellow colored dessert served and a roll in a baggie. The following temperatures were obtained from the test tray: [Note: All temperatures were in degrees Fahrenheit.] a. The popcorn chicken was 97.5 and cold to the taste. It was hard on the outside with lots of breading and hard to chew. b. The rice was 98.6 and cold to the taste.c. The brussel sprouts were 94.1 with a brown/dark green in color with a mushy texture. The brussel sprouts were cold to

the taste. d. The dessert was 63.8. The dessert was pineapple with a cinnamon crumble top. The dessert's flavor had a strange combination of flavors. Resident council minutes from 1/7/25, 2/4/25, 3/5/25, and 5/6/25, there were complaints of cold food. On 6/3/25, the concerns being followed up on did not have cold food as a concern. On 12/30/25 at 11:30 AM, an interview was conducted with [NAME] 2. [NAME] 2 stated

the plates were warmed and put into the liner with a dome over the top when serving food. [NAME] 2 stated there were not enough liners, so pellets were used when the cooks ran out of the liners. [NAME] 2 stated that pellets were not used with the plastic liners. [NAME] 2 stated the pellets were warmed and got really hot but by the time the pellet was provided to the resident it was cool enough to touch. On 12/30/25 at 12:28 PM, an interview was conducted with the Dietary Supervisor (DS). The DS stated kitchen staff should use a liner/base, then a pellet in the base, the plate, and a dome over the top of it. The DS stated the pellets should not be used without the liner/base. The DS stated there were not enough bases for all the residents in the facility. The DS stated the pellets were used to hold in heat and should be warmed to the point that staff could not touch them. The DS stated there were complaints of cold food but then there was staff turnover in the kitchen and in the last 5 months there have not been as many food complaints.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestwood Rehabilitation and Nursing

3665 Brinker Avenue Ogden, UT 84403

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Based on observation, interview, and record review, it was determined the facility did not provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, a sign was hung in the elevator instructing residents that water was the only beverage available between meals and coffee was served at specific times. Findings include: On 12/30/25,

a sign was observed in the resident elevator. The sign revealed UPCOMING CHANGES!!! COFFEE WILL NOW START BEING SERVED AT 7 am AT THE EARLIEST COFFEE AND JUICE WILL ONLY BE SERVED AT MEAL TIMES AND WE ARE NO LONGER FILLING UP MUGS WITH JUICE OR COFFEE! IF YOU WANT TO HAVE ANY BEVERAGES BESIDES WATER BETWEEN MEAL TIMES YOU WILL HAVE TO PROVIDE YOUR OWN (WE ARE IN THE PROCESS OF GETTING VENDING MACHINES). THIS WILL BEGIN ON MONDAY NOVEMBER 17TH!!! On 12/30/25 at 12:28 PM, an interview was conducted with the Dietary Supervisor (DS). The DS stated recently there was a policy change that residents were not provided beverages other than water between meal times. The DS stated residents were not allowed to bring their mug to be filled with coffee or juice to the kitchen because of cross contamination concerns. The DS stated they prepoured drinks for meals and put them on the meal tray. The DS stated if a resident asked for something between meals it was against policy to provide it. The DS stated that started at the beginning of November and since implementing that residents have complained. The DS stated coffee was not available all day but if a Certified Nursing Assistant (CNA) asked the kitchen staff for coffee for a resident, then the kitchen staff would get it for the resident.

Event ID:

Facility ID:

If continuation sheet