Creston Specialty Care

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 3 medication carts. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve all of the menu items to seven (7) residents who were ordered pureed diets. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 4 of 8 residents reviewed (Resident #5, #8, #14 and #23) The facility reported a census of 47 residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to date and label previously opened food packages or properly store food in the freezer and dry goods storage room. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to follow the physician's orders for one (1) resident (#56) by failing to apply a leg immobilizer while the resident was in bed. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair during a transfer for 1 of 5 residents dependent on mechanical lift transfers (#40). The facility reported a census of 47 residents.

Inspectors wroteBased on observations, interviews, record reviews, and policy review the facility failed to provide services meeting profession standards for 1 of 3 residents (Resident #2). The facility failed to follow physician orders for provision of medications as per physician orders. The facility had a census of 54.

Inspectors wroteBased on observations, resident and staff interviews, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 4 residents reviewed (Residents #1, 2 and 4). The facility reported a census of 54.

Inspectors wroteBased on clinical record review, staff interview, and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change within federal guidelines for 5 of 5 residents (#2, #17, #31, #34 and #45) reviewed for MDS Assessments. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, clinical record review, family and staff interviews, and policy review, the facility failed to support the residents right to her choice by not assisting the resident in leaving her room despite multiple requests for 1 of 3 residents screened (Resident #33). The facility reported a census of 47. Findings Include: The quarterly Minimum Data Set (MDS) for Resident #33, completed 04/15/2025, documented her brief interview for mental status score as 05, indicating severely impaired cognition. It documented the following relevant diagnoses: cerebrovascular event (stroke), Non-Alzheimer's dementia, anxiety disorder, depression, and vascular dementia with behavioral disturbance. It documented the resident required a wheelchair for mobility and that she was fully dependent on staff for wheelchair mobility. [...]

Inspectors wroteBased on clinical record review, resident and staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 1 of 5 resident reviewed for vaccines (#40). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to administer pain medication according to physician orders for 1 of 3 residents reviewed for pain assessment (Resident #1). The facility reported a census of 57.

Inspectors wroteBased on clinical record review, observations, family interview, staff interviews and facility policy review, the facility failed to maintain a safe environment due to staff members not following safety precautions during resident transfers, resulting in Resident #21 to have three falls in a three month period. This resulted in harm to Resident #21 due to increasing pain, causing the need for increased pain management, and needing a higher level of assistance for transfers. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, interview, guidance from the 2022 US Food & Drug Administration (FDA) Food Code, and facility policy, the facility failed to serve food in a sanitary manner during breakfast meal service. The facility identified a census of 55 residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to protect resident information from unauthorized access for 5 of 5 residents (#33, #54, #59, #219, #268). The facility reported a census of 55 residents.

Inspectors wroteBased on observations, staff interviews, record reviews, and policy review, the facility failed to identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to appropriately perform hand hygiene and failed to protect stock treatment supplies from cross-contamination. The facility reported a census of 55 residents.

Inspectors wroteBased on observations, resident interview, staff interviews, clinical record review, and facility policy the facility failed to provide dignity by leaving a trash bag with bandage wrappers on a resident's bed (Resident #54). The facility further failed to provide dignity to Resident #54 by not putting his socks back on and covering his legs. The facility reported a census of 55 residents. Findings Include: Review of the Progress Note in the Electronic Medical Record (EHR) dated 5/31/24 completed by Director of Nursing (DON) revealed Resident #54 scored 14/15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 presented upon admission to the facility with 2 stage II pressure ulcers. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 25 opportunities for errors resulting in an error rate of 8% (Residents #23). The facility identified a census of 55 residents.

Inspectors wroteBased on clinical record review, staff interviews, Nurse Practitioner (NP) interview and facility policy review the facility failed to assess weights per orders, lung assessments and edema assessments per care plan for 1 of 3 residents reviewed with Congestive Heart Failure (Resident #3). The facility identified a census of 55 residents.