Creswell Post Acute

In the surveyor’s words

From the most serious findings on record at Creswell Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF695Jan 30, 2026

  Based on observation, interviews, and record review, it was determined the facility failed to provide adequate respiratory care and services for 2 of 2 sampled residents (#s 3 and 4) reviewed for respiratory services. The facility failed to obtain and follow physician orders for tracheostomy care in a timely and consistent manner, which resulted in multiple hospitalizations This placed residents at risk for respiratory complications. Findings include:The 8/1/24 Tracheostomy Care Policy and Procedure Revealed staff were to verify physician orders and identify the resident. The 2025 facility assessment revealed: staff training/competencies and skill sets are required. Clients are reviewed prior to admission to determine if additional training is needed and is provided. 1. […]

• Actual harm, isolatedF689Jan 6, 2022

  Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 1 of 3 sampled residents (# 1) reviewed for accidents. Resident 1 fell and sustained a right [CONDITION(S)]. Findings include: A public complaint was received on 7/13/20 that alleged the facility failed to provide appropriate care and services related to resident's fall. Resident 1 admitted to the facility in 2018 with diagnoses including stroke, abnormal gait and lack of coordination. A comprehensive care plan dated 1/17/20 indicated Resident 1 was a high fall risk and to keep call light in reach, floor free of clutter and Resident 1 was to wear non-skid socks with ambulation. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2026

  Based on observation and interview it was determined the facility failed to ensure an ice machine had the required air gap for 1 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illness. Findings include: On 1/28/26 at 10:04 AM, Staff 8 (Maintenance Director) was observed cleaning the ice machine in the janitor closet on the North Hall. Staff 8 stated he did not know what an airgap was or if the ice machine had an airgap (space between a water pipe sink or drain that prevents dirty water from flowing back into the clean water supply). Staff 8 confirmed the drainpipe was located below the sink basin and stated he did not believe this presented a problem in the event of the sink backflow. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2026

  Based on observation and interview it was determined the facility failed to properly sanitize and store resident care equipment for 1 of 3 halls reviewed for infection control. This placed residents at risk for exposure to blood borne pathogens and cross contamination. Findings include:1. On 1/28/26 at 11:19 AM Staff 6 (LPN) was on the central hall checking CBGs (blood sugar measurement) and moved to the south hall. Staff 6 had one glucometer on top of the medication cart with no cleaning supplies in sight. Staff 6 stated he cleaned the glucometer with an alcohol pad and opened the drawer and pointed to small alcohol prep pads. At this time another staff provided Staff 6 with the purple top Super Sani-Cloth Wipes. […]

• No harm, potential for more than minimal, patternF661Oct 9, 2024

  Based on interview and record review it was determined the facility failed to complete a discharge summary which included a final summary of the resident's status for 3 of 4 sampled residents (#s 2, 4, and 5) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: 1. Resident 2 was admitted to the facility in July 2024, with diagnoses including diabetes. Review of a Discharge Summary/Plan of Care form dated 8/28/24, revealed the final summary of the resident's status did not include all items consistent with the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 2. […]