Safety Report: Crestwood Care Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
3Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
14Requirements cited on more than one inspection
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F697
K
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
L
Government finding: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Tag F835
K
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
4Abuse, neglect & exploitation
2Infection control
10Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (13) than in the cycle before (17).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 4 | March 25, 2025; February 27, 2025; December 16, 2024; May 22, 2024 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 3 | July 10, 2026; March 25, 2025; November 1, 2023 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 3 | February 27, 2025; October 18, 2023; September 30, 2022 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | February 27, 2025; September 30, 2022 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | February 27, 2025; April 11, 2024 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | February 27, 2025; October 3, 2019 |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F584) | 2 | February 27, 2025; October 18, 2023 |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (F727) | 2 | September 25, 2024; May 22, 2024 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | May 22, 2024; April 11, 2024 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F607) | 2 | May 22, 2024; March 4, 2024 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | May 22, 2024; September 30, 2022 |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F761) | 2 | April 11, 2024; October 3, 2019 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F804) | 2 | March 4, 2024; September 30, 2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | January 8, 2024; October 3, 2019 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| September 25, 2024 | Fine | $39,130 |
| January 8, 2024 | Payment Denial | Payment denial for 122 days, starting February 3, 2024 |
| January 8, 2024 | Fine | $193,074 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 10, 2026 — 1 citation · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected July 17, 2026
March 25, 2025 — 4 citations · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected April 4, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected April 4, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected April 4, 2025
D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F620 · complaint · corrected April 4, 2025
February 27, 2025 — 12 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected April 4, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected April 4, 2025
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected April 4, 2025
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · complaint · corrected April 4, 2025
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected April 4, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected April 4, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected April 4, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected April 4, 2025
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected April 4, 2025
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected April 4, 2025
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected April 4, 2025
C
Observe each nurse aide's job performance and give regular training.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F730 · corrected April 4, 2025
December 16, 2024 — 2 citations · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected December 27, 2024
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · complaint · corrected December 27, 2024
September 25, 2024 — 4 citations (includes serious) · complaint investigation
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected October 21, 2024
F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · complaint · corrected October 21, 2024
D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F742 · complaint · corrected October 21, 2024
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · complaint · corrected October 21, 2024
May 22, 2024 — 6 citations · complaint investigation
F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · complaint · corrected June 4, 2024
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected June 4, 2024
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected June 4, 2024
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · complaint · corrected June 4, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 4, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected June 4, 2024
April 11, 2024 — 5 citations (includes serious) · complaint investigation
K
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected June 4, 2024
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected June 4, 2024
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · complaint · corrected June 4, 2024
D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · complaint · corrected May 22, 2024
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · complaint · corrected June 4, 2024
March 4, 2024 — 6 citations · complaint investigation
F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · complaint · corrected May 22, 2024
F
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
No actual harm, but potential for more than minimal harm · Widespread · Resident Rights Deficiencies · F942 · complaint · corrected May 22, 2024
F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F804 · complaint · corrected May 22, 2024
F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected June 4, 2024
E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F712 · complaint · corrected June 4, 2024
D
Prepare residents for a safe transfer or discharge from the nursing home.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F624 · complaint · corrected May 22, 2024
January 8, 2024 — 2 citations (includes serious) · complaint investigation
L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Immediate jeopardy to resident health or safety · Widespread · Administration Deficiencies · F835 · complaint · corrected June 4, 2024
K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 4, 2024
November 1, 2023 — 2 citations · complaint investigation
F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F809 · complaint · corrected November 20, 2023
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected November 20, 2023
October 18, 2023 — 2 citations · complaint investigation
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected November 20, 2023
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected November 20, 2023
September 30, 2022 — 11 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected February 13, 2023
F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F804 · corrected February 13, 2023
D
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F881 · corrected February 13, 2023
D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F773 · corrected February 13, 2023
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected February 13, 2023
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected February 13, 2023
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected February 13, 2023
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected February 13, 2023
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected February 13, 2023
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected February 13, 2023
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected February 13, 2023
October 3, 2019 — 6 citations
E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected November 20, 2019
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected November 20, 2019
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected November 20, 2019
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected November 20, 2019
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected November 20, 2019
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected November 20, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare