Creston Specialty Care

In the surveyor’s words

From the most serious findings on record at Creston Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 2, 2022

  Based on observations, clinical and facility record review, and staff interviews, the facility failed to implement interventions and provide adequate supervision and proper use of assistive devices to mitigate a resident's risk for elopement and an accident for 2 of 5 residents reviewed (Resident #1 and 2). Elopement is when a cognitively impaired resident leaves the facility without staff knowledge or permission. On 8/16/22 sometime between 3:45 AM and 4:15 AM Resident #1 exited the building. The staff stated the doors were alarming but were ignored. The staff were not aware the resident had left the building until the hospital called informing them she was in their emergency room . […]

• Actual harm, isolatedF689Jun 20, 2024

  Based 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. Findings include: The Minimum Data Set (MDS) Assessment of Resident #21, dated 4/23/24 identified a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. […]

• Actual harm, isolatedF684Jan 4, 2024

  Based 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. Findings include: A Minimum Data Set (MDS) assessment form dated 11.15.23 indicated Resident #3 had diagnosis that included anemia, atrial fibrillation (AF), renal insufficiency/failure, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypovolemic shock and a history of urinary tract infections. […]

• Actual harm, isolatedF689Nov 23, 2021

  Based on observations, clinical record and facility policy review, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed (Residents # 47, # 62, and # 66). On 12/30/20, Staff G, Certified Nursing Assistant (CNA) assisted Resident # 66 to the bathroom without a using a gait belt in accordance with facility policy and then proceeded to leave the resident unattended before reaching the inside of the bathroom or assisting her to the toilet in accordance with her plan of care. As a result, the resident fell and hit her head, sustained a hematoma to the back of her head, and exhibited a change in mental status which required the facility to transfer her to the hospital for evaluation. […]

• No harm, potential for more than minimal, patternF761Jul 1, 2026

  Based 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. Findings include:Continuous observation on 6/28/26 at 3:37 PM an unlocked treatment cart at the nurses' station with no staff present. Observed 6 residents in the area seated in wheelchairs or dining chairs in the living/dining area. The medication cart contained the following:The top right drawer contained stock medications including aspirin 81, Bisacodyl, magnesium, acetaminophen.The second right drawer down contained prescribed medications for 12 residents.The third right drawer down contained prescribed medications for 9 residents.The bottom right drawer contained… […]