Crestwood Rehabilitation And Nursing

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestwood Rehabilitation and Nursing

3665 Brinker Avenue Ogden, UT 84403

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: