The Creston Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Creston Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 15, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure residents' change of condition was assessed for 2 of 6 sampled residents (#s 38 and 89) reviewed for hospitalization and unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in the delayed assessment of Resident 89 when she/he was experiencing a significant change in condition, resulting in delayed treatment. Resident 89 later died at the hospital. This placed all residents at risk for delayed assessments and treatments and constituted substandard quality of care. […]

• Actual harm, isolatedF689Feb 27, 2026

  Based on observation, interview and record review it was determined the facility failed to follow care plan interventions to ensure safe transfers and prevent falls for 3 of 4 sampled residents (#'s 2, 48 and 74) reviewed for accidents. This failure resulted in resident 74 having a fall and sustaining an ankle fracture requiring emergency medical services. Findings include: The facility's undated Fall Prevention Program Policy revealed the following: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.-Interventions will be monitored for effectiveness, and the plan of care will be revised and needed. […]

• Actual harm, isolatedF825Oct 15, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 1 of 1 sampled resident (#20) reviewed for rehabilitation and restorative. This failure resulted in Resident 20 displaying a depressed mood, verbalizing feelings of frustration and a decline in physical functioning. Findings include: The facility's 1/2023 Therapy Evaluation Policy indicated the following: -The Rehabilitation Department was to be notified when a physician order was written for therapy evaluation and treatment. […]

• Actual harm, isolatedF661Jul 30, 2024

  Based on interview and record review, the facility failed to complete a discharge summary with required information for wound care and possible wound infection for 1 of 1 sampled resident (# 17) reviewed for unsafe discharge. The facility's failure to provide instructions for the care of the wound and the possible wound infection in the discharge summary information caused the resident's wound to worsen at home resulting in re-admission to a hospital. Findings include: Resident 17 was admitted to the facility in 5/2024 with diagnoses including hip fracture with surgical repair, heart failure, and a history of falling. Resident 17's care plan dated 5/14/24 indicated the resident required frequent skin inspections. […]

• No harm, potential for more than minimal, widespreadF847Oct 15, 2024

  Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights. Findings include: On 10/14/24 at 1:01 PM Staff 1 (Administrator) stated the facility offered a Mediation and Arbitration Clause to residents upon admission. Staff 1 stated he and Staff 5 (Bookkeeper) were responsible for the process of explaining the agreement to residents upon admission. On 10/14/24 at 1:06 PM Staff 5 stated she was responsible to provide residents with information related the facility's Mediation and Arbitration Clause. […]