Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crest Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure that licensed nursing staff adhered to prescribed oxygen delivery rates for three residents. Records showed that oxygen levels frequently exceeded the prescribed limits, despite facility policy requiring adherence to physician orders. Interviews confirmed that nursing staff were aware of the need for provider orders to change oxygen rates.
The facility failed to manage portable oxygen tanks properly, resulting in a resident's oxygen saturation dropping to 86%. Staff interviews revealed that tanks were not replaced promptly, and there was a lack of documentation for provider notifications and interventions when oxygen levels fell below 90% for two residents. Records showed numerous omissions in documenting oxygen settings over several months.
The facility failed to change and label oxygen tubing for four residents requiring respiratory care, despite the protocol for weekly changes. Observations and staff interviews revealed inconsistencies in following the protocol, with some tubing not labeled or changed as required. The TAR indicated the changes were documented, but observations suggested otherwise.
The facility failed to ensure a resident's GDR request for fluoxetine was responded to by the physician and completed. Despite multiple GDR requests from the consultant pharmacist, there was no response until the surveyors intervened. Staff interviews indicated a lack of documentation and timely action regarding the GDR request.
Failure to Adhere to Prescribed Oxygen Delivery Rates
Penalty
Summary
The facility failed to ensure that licensed nursing staff adhered to accepted standards of practice by administering oxygen within the parameters of the provider's orders for three residents prescribed supplemental oxygen. For Resident #5, the Treatment Administration Record showed that from September 2024 through March 2025, the oxygen levels delivered frequently exceeded the prescribed one liter per minute. Similarly, Resident #6's records indicated that from October 2024 through January 2025, the oxygen levels delivered often exceeded the prescribed two liters per minute. Resident #4's records from November 2024 through January 2025 also showed instances where the oxygen levels exceeded the prescribed maximum of two liters per minute. Interviews with staff members revealed that nursing was the only discipline allowed to change oxygen levels, and a new provider order was required to adjust a resident's oxygen rate of flow if it was outside the existing order parameters. The facility's policy, titled 'Oxygen - Appropriate Use, Management and Storage,' emphasized that oxygen should be treated as a medication, and licensed nurses must follow a physician's order for oxygen delivery. Despite this policy, the facility's nursing staff did not consistently adhere to the prescribed oxygen delivery rates, leading to the identified deficiencies.
Failure to Manage Portable Oxygen Tanks and Document Interventions
Penalty
Summary
The facility failed to ensure proper management of portable oxygen tanks for residents requiring supplemental oxygen. Specifically, a resident was observed with a portable oxygen tank that was empty, resulting in an oxygen saturation level of 86%, below the prescribed threshold of 90%. Staff interviews revealed that while all staff were responsible for checking oxygen levels, there were instances where the tanks were not replaced promptly, leading to dangerously low oxygen levels. Despite staff awareness of the issue, the problem persisted, with one staff member expressing concern about the resident's oxygen levels dropping as low as 74%. Additionally, the facility did not consistently document provider notifications, nursing assessments, or interventions when residents' oxygen saturation levels fell below the prescribed parameters. For two residents, there were multiple occurrences where oxygen levels were below 90%, yet there was no documentation of any action taken. This lack of documentation spanned several months, indicating a systemic issue in monitoring and responding to residents' oxygen needs. The facility's records showed numerous omissions in documenting whether the oxygen was turned on and set at the correct flow rate. This lack of documentation was evident over several months, with multiple omissions each month. Staff interviews confirmed that vital signs, including oxygen levels, were checked by CNAs and reported to nurses if abnormal, but the follow-up actions were not consistently recorded in the residents' records.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to change and label resident oxygen tubing for four of five sampled residents requiring respiratory care. Resident #34 was observed with oxygen tubing labeled and dated thirteen days prior, despite the facility's protocol requiring weekly changes. Staff interviews revealed inconsistencies in following the protocol, with one staff member acknowledging the tubing should have been changed the previous week. Resident #34 had a history of respiratory failure and was on a reduced oxygen level. The Treatment Administration Record (TAR) indicated the tubing change was documented as completed, although observations suggested otherwise. Resident #33 was observed with undated oxygen tubing on two separate occasions. Staff interviews confirmed the protocol for weekly tubing changes, but the tubing was not labeled as required. The TAR showed the tubing change was documented, but observations did not align with this record. Resident #33 had diagnoses of pneumonia, COPD, and obstructive sleep apnea. Similar issues were observed with residents #4 and #28, where the oxygen tubing was either not labeled or not changed as per the facility's policy. The facility's policy on oxygen management required weekly changes and proper documentation, which was not consistently followed for these residents.
Failure to Ensure Timely GDR Response for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident's Gradual Dose Reduction (GDR) request for fluoxetine was responded to by the physician and completed. Resident #34 had a history of depression and was on fluoxetine, with dosage adjustments documented over time. Despite multiple GDR requests from the consultant pharmacist in January, February, and March 2024, there was no response from the physician until the surveyors requested the GDR form on March 27, 2024. The GDR response was completed by the physician on the same day it was requested by the survey team, indicating a delay in addressing the GDR request. Interviews with staff revealed that staff member B was responsible for ensuring GDR requests were responded to by the physician and for documenting conversations about GDRs. Staff member A mentioned that staff member D might have delayed the response due to the resident's hospice status, but there was no documentation to support this. The facility's policy on psychoactive medication protocol requires GDR attempts in two separate quarters within the first year unless clinically contraindicated, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continental Care And Rehabilitation | 0.2 mi | — | 1 | 0 |
| Copper Ridge Health And Rehabilitation Center | 0.3 mi | — | 0 | 0 |
| Southwest Montana Veterans Home | 3.1 mi | — | 0 | 0 |
| Community Nursing Home Of Anaconda | 24 mi | — | 17 | 0 |
| Ivy At Deer Lodge | 30 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.