Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Creston during CMS and state inspections, most recent first.
A resident with significant medical needs, including a feeding tube, did not receive seven scheduled evening medications because a nurse was unable to access the G-tube and did not escalate the issue as expected. The nurse documented the missed doses, and the DON later stated that staff should have sought further assistance. The facility lacked a policy on following physician's orders.
Nursing staff failed to properly administer medications and respond to pain for a resident with a PEG tube. One nurse did not give scheduled medications due to uncertainty about syringe compatibility and did not escalate the issue, while another nurse continued tube feeding despite the resident's complaints of severe pain, later noting abdominal distension. Staff actions did not align with facility policy for feeding tube care and monitoring.
The facility failed to prepare and serve therapeutic meals according to physician orders for three residents with dysphagia, leading to improperly pureed and incorrectly textured diets. A resident with a pureed diet was served food not pureed to the correct consistency, while another resident with a mechanical soft diet was served a regular diet due to a mislabeled tray card. The dietary staff demonstrated inadequate knowledge of proper diet preparation.
The facility failed to maintain proper food temperatures during lunch service, with cold items like creamy cheddar macaroni salad, tomato slices, and deviled eggs exceeding the required 41 degrees Fahrenheit by the end of the meal. Observations showed that cold items were not adequately kept on ice, leading to temperature increases during service.
The facility failed to properly label, date, store, and serve food, with observations of improper glove use and food handling by a cook during lunch service. Despite recent staff education on food safety, these practices were not followed, compromising food safety.
The facility failed to implement proper infection control practices, as staff neglected hand hygiene and equipment sanitation during resident care and medication administration. Observations included improper handling of catheter care, gastric tube site care, and mechanical lift equipment, as well as lapses in hand hygiene during medication administration, including insulin injections and glucometer use.
The facility did not implement required training for five staff members, lacking documentation for completed training in communication, QAPI, compliance and ethics, and behavioral health. Additionally, one staff member did not complete training in resident rights and infection control. The 2024 Mandatory Education calendar required these topics for all staff, but there was no documentation to confirm completion. The DON expected all staff to be current with required training.
The facility did not provide communication training for five staff members hired between March and November 2023, despite it being a required course on the 2024 Mandatory Education calendar. The DON expected all staff to be current with training, but documentation was lacking.
The facility did not provide resident rights training for one staff member, Staff J, who was hired in March 2023. Despite the 2024 mandatory education calendar requiring all staff to complete training on topics including resident rights, there was no documentation showing Staff J's completion of this training. The DON expected all staff to be current with required training, and the facility had a census of 30 residents.
The facility did not provide mandatory QAPI training for five staff members, as required by their education calendar. Despite the Director of Nursing's expectation for all staff to be current with training, there was no documentation confirming completion of QAPI training for these staff members.
The facility did not provide mandatory infection control training for a staff member hired in March 2023. The 2024 education calendar required all staff to complete infection control training, but documentation for this training was missing for one staff member. The DON expected all staff to be current with required training.
The facility did not provide compliance and ethics training for five staff members hired between March and November 2023. Despite being listed as a required course on the 2024 Mandatory Education calendar, there was no documentation of completion for these staff. The DON expected all staff to be current with training, highlighting a lapse in compliance.
The facility did not provide required behavioral health training for five staff members, as revealed by a review of personnel files and the mandatory education calendar. Despite the 2024 education calendar listing behavioral health as a required course, there was no documentation of completion for these staff. The DON expected all staff to be current with training.
The facility failed to notify family and physicians of significant events affecting four residents, including medication errors, a fall, and a change in condition. A resident received incorrect medication dosages without physician notification. Another resident fell, resulting in injuries, but the family was not informed. A third resident experienced delusions after marijuana exposure, but the physician was not updated. These incidents highlight a lack of adherence to notification policies.
The facility failed to update care plans for four residents, leading to deficiencies in care. A resident with swollen legs was on a diuretic, but this was not reflected in their care plan. Another resident, identified as a smoker, lacked smoking safety interventions in their care plan. A third resident's care plan inaccurately described their transfer needs, while a fourth resident's care plan did not include interventions to prevent future falls after an incident.
A resident with severe cognitive impairment experienced a fall while attempting to self-transfer, initially denying pain or injury. The facility's documentation lacked comprehensive post-fall assessments, including vitals and neurological checks. Later, a nurse observed a bruise and the resident complained of leg pain. After transferring to another facility, a fracture was discovered, although no falls occurred there. Hospital records confirmed a right distal femur fracture.
The facility did not document whether a resident wished to appeal the termination of skilled services, as required by policy. The Social Services Manual requires that a Notice of Medicare Non-Coverage (NOMNOC) form be provided to residents two days before service termination, but the facility failed to retain documentation of the resident's decision to appeal. The Social Services Supervisor confirmed that while residents completed the form, the documentation was not kept in the resident's record.
A facility failed to complete a Significant Change MDS within 14 days for a resident admitted to hospice care with cerebral atherosclerosis. The MDS assessment was delayed, contrary to the facility's policy requiring completion within 14 days of a significant change in status. The Regional Director of Nursing indicated that remote MDS Coordinators are responsible for care planning, while on-site staff handle daily updates.
A facility failed to accurately complete the MDS assessment for a resident dependent on HD treatments. Despite the resident's regular HD schedule and documentation in the EHR, the MDS assessment did not reflect these treatments. The interim DON confirmed the omission, which contradicted the facility's RAI/MDS policy.
A facility failed to notify the PASRR program for a resident admitted with mental diagnoses and medications. The resident's PASRR, dated before admission, did not list any mental health conditions or medications, despite the resident having diagnoses of dementia, anxiety, depression, and psychotic disorder, and being on antipsychotic, antianxiety, and antidepressant medications. The social worker confirmed the PASRR was outdated and did not reflect the resident's current medication regimen.
A resident with multiple health conditions did not receive care according to their comprehensive care plan. Staff failed to use a mechanical aid for transfers and did not adhere to the prescribed oxygen settings, leading to deficiencies in care. The resident's oxygen tank was set incorrectly and was empty, and staff transferred the resident manually despite the care plan's directives.
A resident with multiple health conditions was not provided oxygen as per physician orders, receiving 2 LPM instead of the prescribed 3 LPM. Observations showed the oxygen tank was in the refill zone, and staff interviews revealed the facility lacked a policy for following physician's orders.
A facility failed to maintain a medication error rate below 5% during a medication pass. A nurse administered incorrect dosages of Furosemide, Magnesium Oxide, Fiber Lax, and Calcium to two residents, resulting in a 14.8% error rate. The Director of Nursing confirmed that medication orders should be verified against the MAR for accuracy, as outlined in the facility's policy.
A facility failed to maintain a safe environment and proper transfer techniques, as evidenced by an incident where a resident was found with vapes containing nicotine and THC, and another resident was transferred without a gait belt despite being a high fall risk. The facility's policies on smoking and transfer techniques were not followed, leading to these deficiencies.
The facility failed to follow infection prevention standards during incontinence care for two residents. Staff did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks, and the mechanical lift was not disinfected after use. The Director of Nursing confirmed that these actions were against facility policy.
The facility did not review and update its facility-wide assessment annually as required. The last review was documented on 4/26/23, with no updates until 7/10/24. The Regional Director of Clinical Services could not locate the current assessment, and a new one was not completed, despite the facility's policy requiring annual reviews.
The facility did not have a written transfer agreement with a hospital, which is essential for ensuring residents can be transferred for medical care when needed. This was confirmed by the Regional Director of Clinical Services, who noted the absence of both the agreement and a related policy.
A facility failed to update a care plan for a resident with COPD who frequently adjusted her oxygen levels herself. Despite staff and family awareness of this behavior, it was not documented in the care plan, and no specific interventions were implemented to prevent the resident from adjusting her oxygen levels.
Failure to Administer Medications as Ordered Due to Inaccessible G-Tube
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for medication administration for a resident with multiple complex medical conditions, including COPD, anxiety, depression, stroke with right-sided hemiplegia, aphasia, and dysphagia. The resident required significant assistance with daily activities and received more than half of their caloric intake via a feeding tube. The physician's order specified that medications could be crushed and administered through the feeding tube every shift. However, on one occasion, the resident did not receive seven scheduled evening medications because the nurse was unable to access the G-tube. The nurse documented the missed medications and stated that he did not believe missing the nighttime medications would be detrimental. The resident later confirmed not receiving the medications. The DON indicated that staff should have contacted the on-call nurse and escalated the issue if necessary. Additionally, the facility administrator acknowledged that there was no policy in place regarding adherence to physician's orders.
Failure to Ensure Competent G-Tube Care and Response to Resident Pain
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in the care of a resident with a PEG feeding tube, resulting in missed medication administration and improper response to pain during tube feeding. The resident, who had moderately impaired cognition and multiple diagnoses including dysphagia, stroke with hemiplegia, and aphasia, was dependent on tube feeding for more than half of his caloric intake. On one occasion, a registered nurse was unable to administer scheduled evening medications because he could not access the resident's new feeding tube, citing the absence of a specific syringe. The nurse did not contact the on-call nurse or escalate the issue, resulting in the resident missing his medications. It was later determined that available piston syringes would have sufficed for medication administration. On a subsequent shift, another nurse continued to administer tube feeding to the same resident despite the resident's complaints of severe pain and visible discomfort. The nurse attributed the resident's reaction to possible hunger or post-surgical tenderness and did not stop the feeding or seek further assessment. The resident's abdomen was later found to be distended and painful upon examination. Facility policy required staff to utilize feeding tubes according to clinical standards and to monitor for complications, but staff failed to follow these protocols, leading to the deficiency.
Improper Preparation of Therapeutic Meals
Penalty
Summary
The facility failed to prepare and serve therapeutic meals in a form designed to safely meet the needs of residents, as per physician orders. This deficiency was identified for three residents who required specific diet textures due to their medical conditions. Resident #9, who had a diagnosis of dysphagia, was supposed to receive a pureed diet with honey-thick liquids. However, during meal preparation, the food was not pureed to the correct consistency, posing a risk of choking or aspiration. Resident #16, also diagnosed with dysphagia, was on a puree diet for pleasure feedings in addition to tube feedings. The resident had a history of coughing during meals and a previous choking incident. Despite these concerns, the food prepared for Resident #16 was not properly pureed, as observed by the State Surveyor. The macaroni salad, intended to be pureed, was not smooth, and the Registered Dietitian later confirmed that it was not appropriately prepared. Resident #25 was ordered a mechanical soft diet but was incorrectly served a regular diet during lunch observation. The tray card for Resident #25 was mislabeled, leading to the resident receiving the wrong diet. The facility's dietary staff, including Staff B, demonstrated a lack of knowledge and adherence to proper puree and mechanical soft diet preparation, as evidenced by the improper handling and preparation of meals during the surveyor's observation.
Removal Plan
- Meal service for Res #9 and Res #16, puree diets, were audited by the Director of Nursing (DON)/Designee to validate they were served the meal at the correct therapeutic menu and pureed consistency.
- An audit was completed by the DON/Designee to ensure required therapeutic diet consistency was provided as ordered by the physician.
- Dietary staff were re-educated by the DON/Designee regarding the requirements of serving therapeutic diets including pureed consistency per physician's orders. Any dietary staff not trained would be trained prior to the beginning of his/her next scheduled shift.
- An audit set up for completion by the Administrator/Designee weekly to ensure dietary staff continue to provide therapeutic diet consistencies per physician's orders including puree consistency.
Failure to Maintain Proper Food Temperatures During Lunch Service
Penalty
Summary
The facility failed to maintain proper food temperatures during lunch service, as observed on 7/9/24. Prior to the meal service, temperatures of various food items were recorded: creamy cheddar macaroni salad at 40 degrees, fruit at 38 degrees, ham salad at 40 degrees, tomato slices at 38 degrees, bacon at 150 degrees, and deviled eggs at 40 degrees. These cold items were removed from the refrigerator just before the temperatures were checked. The bacon was placed on a steam table set to heat, while the cold items were placed on the opposite end of the steam table, which was turned off, with ice packed in the wells. A full-sized sheet pan of deviled eggs was placed on the counter with a cake pan of ice underneath, but during meal service, the sheet pan was moved, leaving half of the deviled eggs over the ice. By the end of the meal service at 12:43 pm, the temperatures of the creamy cheddar macaroni salad, tomato slices, and deviled eggs had risen to 50 degrees, 58 degrees, and 60 degrees, respectively. According to the facility's document on Sanitation and Food Production, cold foods should be maintained at or below 41 degrees Fahrenheit. Staff C, the current Activity Director and former Dietary Manager, confirmed that cold foods should be kept at 41 degrees or colder and that the procedure involves filling the steam table wells with ice for cold foods.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to properly label, date, store, and serve resident foods, as observed during a survey. During an initial walkthrough of the kitchen, several items were found improperly stored in the refrigerator, including a half-empty gallon of chocolate milk with no open date, three bottles of cola without labels or dates, and a bowl of hard-boiled eggs without protective wrap or date. These findings indicate a lack of adherence to food storage policies. During lunch service, Staff B, a cook, was observed handling food improperly. She did not change gloves or perform hand hygiene after handling various items, including the steam table lid, bread, and deviled eggs. Staff B also failed to maintain proper puree texture for a resident's meal, requiring intervention from another staff member. Despite being instructed to discard the improperly pureed macaroni salad, Staff B continued to handle food without changing gloves or washing hands, further compromising food safety. The Registered Dietitian noted that gloves can give a false sense of security, and the facility's policy emphasized the need for glove changes after contamination. Despite recent staff education on food safety, including glove use and food storage, these practices were not followed during the survey. The Dietary Manager was absent during the survey, and oversight was provided by the Activities Director, who confirmed that staff education would continue to address these issues.
Infection Control Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple observations of staff neglecting hand hygiene and equipment sanitation. During catheter care for a resident with severe cognitive impairment, staff members did not perform hand hygiene between glove changes and handled the catheter drainage bag improperly, contrary to the care plan instructions. Additionally, the staff did not maintain the catheter bag below the bladder level, increasing the risk of infection. In another instance, a registered nurse performed gastric tube site care for a resident with a feeding tube without adhering to proper hand hygiene protocols. The nurse opened supplies before donning gloves and failed to perform hand hygiene between glove changes during the procedure. This oversight in infection control practices was further compounded by the improper handling of mechanical lift equipment, which was not disinfected after use, as observed during the care of two residents requiring assistance with transfers and incontinent care. The facility's medication administration process also demonstrated significant lapses in infection control. A registered nurse failed to perform hand hygiene before and after administering medications, including insulin injections and inhaled medications, to two residents. The nurse also neglected to sanitize a glucometer used for blood sugar testing, which was initially placed in a general area of the medication cart before being moved to a resident-specific section. These actions were inconsistent with the facility's medication administration policy, which mandates hand hygiene at specific points during the process.
Failure to Implement Required Staff Training
Penalty
Summary
The facility failed to implement required training for five staff members, as evidenced by a lack of documentation for completed training in several mandatory topics. The personnel file review, mandatory education calendar, and staff interviews revealed that Staff F, G, H, I, and J did not complete training in communication, Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and behavioral health. Additionally, Staff J did not complete training in resident rights and infection control. The facility's 2024 Mandatory Education calendar listed these topics as required for all staff, yet there was no documentation to confirm the completion of these trainings. The Director of Nursing (DON) confirmed the expectation that all staff should be current with required training.
Failure to Implement Communication Training for Staff
Penalty
Summary
The facility failed to implement communication training for five staff members, as revealed through personnel file reviews, the facility's mandatory education calendar, and staff interviews. The staff members in question, identified as Staff F, G, H, I, and J, were hired between March 1, 2023, and November 16, 2023. Despite the facility's 2024 Mandatory Education calendar listing effective communication as a required course for all staff, there was no documentation indicating that these staff members completed the necessary training. The Director of Nursing confirmed the expectation that all staff should be current with required training, yet the deficiency in communication training was evident.
Failure to Implement Resident Rights Training for Staff
Penalty
Summary
The facility failed to implement resident rights training for one of the five staff members reviewed, specifically Staff J, who was hired on March 28, 2023. The facility's mandatory education calendar for 2024 included topics such as effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health, all of which were required for all staff. However, there was a lack of documentation indicating that Staff J had completed the required training in resident rights. During a phone interview on July 11, 2024, the Director of Nursing stated that she expected all staff to be current with the required training. The facility reported a census of 30 residents at the time of the survey.
Failure to Implement Mandatory QAPI Training
Penalty
Summary
The facility failed to implement mandatory Quality Assurance and Performance Improvement (QAPI) training for five staff members, as required by their education calendar. The personnel file review and staff interviews revealed that Staff F, G, H, I, and J did not complete the QAPI training. The facility's 2024 Mandatory Education calendar listed QAPI as a required course for all staff, alongside other topics such as effective communication, resident rights, infection control, compliance and ethics, and resident behavioral health. Despite these requirements, there was no documentation to confirm that the mentioned staff members had completed the necessary QAPI training. The Director of Nursing expected all staff to be current with their required training, but this expectation was not met for the staff reviewed.
Failure to Implement Infection Control Training
Penalty
Summary
The facility failed to implement mandatory infection control training for one of the five staff members reviewed, identified as Staff J. The review of personnel files, the facility's mandatory education calendar, and staff interviews revealed that Staff J, who was hired on March 28, 2023, did not have documentation of completed infection control training. The facility's 2024 Mandatory Education calendar listed infection control as a required course for all staff, along with other topics such as effective communication, resident rights, QAPI, compliance and ethics, and resident behavioral health. During a phone interview, the Director of Nursing stated that all staff were expected to be current with the required training.
Failure to Implement Compliance and Ethics Training
Penalty
Summary
The facility failed to implement compliance and ethics training for five staff members, as revealed through personnel file reviews, the facility's mandatory education calendar, and staff interviews. The staff members in question were hired between March and November 2023, and the facility did not have documentation showing that these staff members completed the required training in compliance and ethics. The facility's 2024 Mandatory Education calendar listed compliance and ethics as a required course for all staff. Despite this requirement, the Director of Nursing stated that all staff were expected to be current with their training, indicating a lapse in ensuring compliance with the training schedule.
Failure to Implement Behavioral Health Training
Penalty
Summary
The facility failed to implement behavioral health training for five staff members, as required by their facility assessment. A review of personnel files, the mandatory education calendar, and staff interviews revealed that Staff F, G, H, I, and J did not complete the necessary training in behavioral health. The facility's 2024 Mandatory Education calendar listed behavioral health as a required course for all staff, alongside other topics such as effective communication, resident rights, QAPI, infection control, and compliance and ethics. Despite these requirements, there was no documentation to confirm that the training had been completed by the staff members in question. The Director of Nursing stated that all staff were expected to be current with their required training.
Failure to Notify Family and Physician of Significant Events
Penalty
Summary
The facility failed to notify the family and/or physician of significant events affecting four residents, including medication errors, a fall, and a significant change in condition. For Resident #26, a medication pass observation revealed that three medications were administered at incorrect dosages, and for Resident #3, one medication was administered at an incorrect dosage. Despite the facility's policy requiring notification of the physician in such cases, the progress notes for both residents did not indicate that the physician had been informed of these errors. Resident #34 experienced a fall, resulting in a bruise on the forehead and pain in the legs, which was not communicated to the family. The resident, who has severe cognitive impairment, was found on the floor after attempting to self-transfer. Although the nurse on call and the physician were notified, the Power of Attorney/Emergency Contact was not informed, as documented in the Risk Management form and progress notes. Resident #24, also with severe cognitive impairment, was found in another resident's room exposed to marijuana, leading to a significant change in condition, including delusions and altered assistance needs. The resident's daughter was informed of the marijuana exposure, but the physician was not updated about the delusions, contrary to the facility's policy. The staff noted the resident's condition was not typical, requiring more assistance than usual, but failed to notify the physician of the change in condition.
Deficiencies in Care Plan Revisions and Updates
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. Resident #26, who had intact cognition and multiple diagnoses including hypertension and deep vein thrombosis, was observed with swollen legs and feet. Despite being on a diuretic medication, the care plan did not include this medication or any related interventions. The interim Director of Nursing acknowledged that care plans should be continuously revised to meet residents' needs, but this was not done for Resident #26. Resident #11, who was totally dependent on staff for care and had intact cognition, was identified as a smoker. However, the comprehensive care plan did not reflect this, despite the resident being listed as a smoker in a facility document. Observations confirmed that Resident #11 required staff assistance for vaping, yet the care plan lacked necessary interventions for smoking safety, as outlined in the facility's smoking policy. Resident #12, with severe cognitive impairment and total dependence on staff, had a care plan that inaccurately described their transfer needs. The care plan stated the resident could transfer with one assist and a walker, but observations and progress notes indicated the use of a mechanical lift for transfers. Additionally, Resident #34, with severe cognitive impairment, had a care plan addressing fall risk but lacked interventions to prevent future falls after an incident. The facility's policy required a full investigation and care plan update after such incidents, which was not completed.
Failure to Conduct Comprehensive Post-Fall Assessment
Penalty
Summary
The facility failed to perform complete and accurate assessments following a fall for a resident with severe cognitive impairment. The resident was found on the floor beside her bed, having attempted to self-transfer, and initially denied any pain or injury. However, the progress notes lacked comprehensive documentation of the fall, including assessments, vitals, or neurological checks. A nurse from the resident's previous facility later observed a bruise on the resident's forehead and reported that the resident complained of leg pain. Subsequently, a family member reported that after the resident was transferred to another facility, x-rays revealed a fractured leg, although the resident had not experienced any falls at the new facility. Hospital records confirmed a right distal femur fracture, with the timeline of the injury undetermined. The Regional Director of Clinical Services indicated that a Risk Management form should have been initiated, followed by a full investigation and intervention in the resident's care plan, with follow-up charting for 72 hours post-incident.
Failure to Document Resident's Appeal Decision for Termination of Skilled Services
Penalty
Summary
The facility failed to document whether a resident wished to appeal the decision to end skilled services, as required by their policy. This deficiency was identified for one resident who was discharged from skilled services. The facility's Social Services Manual mandates that a completed Notice of Medicare Non-Coverage (NOMNOC) form be provided to residents at least two days before the termination of services, allowing them the opportunity for an independent medical review. However, the facility did not maintain documentation of the resident's decision to appeal the termination of services. The Social Services Supervisor confirmed that while residents filled out the form, the documentation regarding their decision to appeal was not retained in the resident's record.
Failure to Timely Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) within 14 days for a resident who was placed on hospice care. The clinical record review, staff interview, and facility policy review revealed that the resident was admitted to hospice care with a diagnosis of cerebral atherosclerosis. The MDS assessment indicated a significant change in status, but the completion of the MDS was delayed until 6/5/24, beyond the required 14-day period. The facility's policy mandates that comprehensive assessments, including significant change assessments, must be completed within 14 days after determining a significant change in the resident's status. The Regional Director of Nursing noted that MDS Coordinators are remote and responsible for care planning based on Care Area Assessments (CAA), while daily updates are the responsibility of on-site staff, including a Licensed Practical Nurse or the Director of Nursing.
Inaccurate MDS Assessment for Hemodialysis Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident who was dependent on hemodialysis (HD) treatments. The resident, who had a history of congestive heart failure, chronic kidney disease, end-stage renal disease, and diabetes mellitus, received HD treatments every Monday, Wednesday, and Friday. However, the Admission MDS assessment did not include the resident's HD treatments during the 7-day look-back period, despite documentation in the Electronic Health Record (EHR) indicating the resident received HD on specific dates. The interim Director of Nursing acknowledged that the resident's HD should have been included in the MDS assessment, as required by the facility's policy on the Resident Assessment Instrument (RAI)/MDS.
Failure to Notify PASRR for Resident with Mental Diagnosis
Penalty
Summary
The facility failed to notify the Preadmission Screening and Resident Review (PASRR) program for a resident with a mental diagnosis and medications. The resident was admitted to the facility with a PASRR dated prior to admission, which did not list any mental diagnosis or medications. However, the Minimum Data Sheet (MDS) assessment revealed that the resident was admitted with diagnoses of unspecified dementia with behavioral disturbance, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. The resident was also admitted with drug classifications of antipsychotic, antianxiety, and antidepressant medications. The facility's social worker confirmed that the only PASRR available for the resident was dated before admission and did not reflect the resident's current medication regimen. The social worker stated that a new PASRR is typically submitted before residents are admitted, but in this case, the medications were incorrect upon admission. The resident was not initially taking antipsychotic medication, but it was started as a trial after admission. The facility's policy requires verification of mental illness or developmental disability diagnoses and contacting the appropriate state agency for a Level II screen, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, leading to deficiencies in care. The resident, who had diagnoses of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and non-Alzheimer's dementia, required maximum assistance with transfers and was dependent on oxygen. Despite a physician's order for oxygen at 3 liters per minute via nasal cannula, staff were observed transferring the resident without a gait belt and using incorrect oxygen settings. The resident's oxygen tank was set at 2 liters per minute, contrary to the prescribed 3 liters, and the tank was in the red, refill zone, indicating it was empty. Additionally, the care plan directed staff to use a mechanical aid for transfers, which was not followed. Staff were observed transferring the resident manually, without the use of the mechanical aid as required. The interim Director of Nursing confirmed that staff should adhere to doctor's orders and therapy expectations, including the use of mechanical aids when ordered. The facility's policies on transfer techniques and oxygen administration were not followed, contributing to the deficiency in care for the resident.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to provide oxygen per physician orders for a resident, as observed during a survey. The resident, who had diagnoses of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and non-Alzheimer's dementia, was supposed to receive oxygen at 3 liters per minute (LPM) via nasal cannula continuously, according to a physician's order dated 10/13/23. However, on multiple occasions, the resident was observed receiving oxygen at a lower rate of 2 LPM, and the portable oxygen tank was found in the red, refill zone, indicating it was empty or nearly empty. Staff interviews revealed that the facility did not have a policy for following physician's orders, and the interim Director of Nursing stated that staff should adhere to doctor's orders and therapy expectations. Despite this, the resident's oxygen was not administered as prescribed, with the oxygen concentrator set at 2.5 LPM instead of the ordered 3 LPM. The lack of adherence to the physician's order and the absence of a policy for following such orders contributed to the deficiency identified by the surveyors.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a medication pass on July 9, 2024. During this observation, a Registered Nurse administered medications to two residents. For the first resident, 19 medications were administered, including Furosemide, Magnesium Oxide, and Fiber Lax. For the second resident, 8 medications were administered, including Calcium. Upon reviewing the Medication Administration Record (MAR) for both residents, discrepancies were found between the medications ordered and those administered. Specifically, the dosages of Furosemide, Magnesium Oxide, Fiber Lax, and Calcium did not match the orders in the MAR. The errors resulted in a medication error rate of 14.8%, significantly exceeding the acceptable threshold of 5%. The Director of Nursing acknowledged that all medication orders should be verified for accuracy against the MAR before administration. The facility's policy on Medication Administration, dated January 2013, outlines the necessary steps for verifying medication orders, including checking the MAR for the correct medication, dose, route, and time, and ensuring the pharmacy prescription label matches the MAR. However, these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Maintain Safe Environment and Proper Transfer Techniques
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by an incident involving Resident #11 and two other residents. Staff F, a registered nurse, discovered Resident #11 in a room with two other residents, where a strong odor of marijuana was present, and two vapes were found on Resident #11's chest. Despite Resident #11 being listed as a smoker in an untitled facility document, the comprehensive care plan did not indicate this. The incident was reported to the local police, and the vapes were identified as containing nicotine and THC, although no charges were filed. Another deficiency was observed when Staff I, a certified nurse aide, transferred Resident #9 without using a gait belt, contrary to the facility's policy. Resident #9, who has diagnoses including heart failure, COPD, chronic kidney disease, and non-Alzheimer's dementia, was assessed as a high fall risk and required maximum assistance with transfers. The care plan directed the use of a mechanical aid for transfers, but Staff I manually transferred the resident without the required equipment, increasing the risk of injury. The facility's policies on smoking and transfer techniques were not adhered to, leading to these deficiencies. The smoking policy required that smoking materials be secured by the facility and designated smoking areas be used, while the transfer policy mandated the use of a gait belt unless otherwise ordered. These lapses in following established protocols contributed to the unsafe conditions observed during the survey.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to adhere to infection prevention standards during incontinence care for two residents. Resident #6, who has short and long-term memory problems and is totally dependent on staff for toileting and personal hygiene, was observed receiving incontinence care without proper hand hygiene practices. Staff did not change gloves or wash/sanitize hands when transitioning from dirty to clean tasks. Additionally, the mechanical lift used during the care was not disinfected after use, contrary to facility policy. Resident #12, who has severe cognitive impairment and is dependent on staff for all care except eating, also received incontinence care without proper infection control measures. Staff failed to change gloves and perform hand hygiene when moving from dirty to clean tasks. Similar to the care provided to Resident #6, the mechanical lift was not disinfected after use. The facility's policy on perineal care, which includes specific steps for hand hygiene and glove changes, was not followed. The Director of Nursing confirmed that staff should perform hand hygiene before and after incontinence care, change gloves when soiled, and clean mechanical lift equipment per policy. The facility's failure to follow these procedures during the care of Residents #6 and #12 resulted in a deficiency related to infection prevention standards.
Failure to Annually Review Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment annually, as required. The last documented review of the facility assessment was dated 4/26/23, and there was no evidence of any review or update conducted between 4/26/23 and 7/10/24. On 7/09/24, the Regional Director of Clinical Services was unable to locate the current facility assessment, and a new assessment had not been completed. The facility's policy, reviewed on 12/19/24, mandates that the facility assessment be reviewed at least annually.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with a hospital, which is necessary to ensure that residents can be promptly transferred to a hospital when they require medical care. This deficiency was identified through a review of facility documents and staff interviews. The facility, which reported a census of 30 residents, lacked documentation of such an agreement with a local hospital. During a phone interview, the Regional Director of Clinical Services confirmed that the facility did not have a transfer agreement in place, although the Administrator had been in contact with a hospital to address this issue. Additionally, the facility did not have a policy regarding hospital transfer agreements.
Failure to Update Care Plan for Resident with COPD
Penalty
Summary
The facility failed to update and revise a resident care plan to reflect non-compliance with physician orders for a resident with COPD. The resident, who had a history of adjusting her oxygen levels, was found to have her oxygen concentrator within reach, allowing her to change the settings herself. Despite multiple staff members and a family member being aware of this behavior, it was not documented in the care plan, and no specific interventions were put in place to prevent the resident from adjusting her oxygen levels. The resident's Minimum Data Set (MDS) indicated that she had intact cognition and required supervision for bed mobility and transfers. The resident had multiple diagnoses, including high blood pressure, renal failure, diabetes mellitus, anxiety, depression, COPD, and chronic respiratory failure with hypoxia. The care plan directed staff to provide oxygen therapy as ordered by the physician but did not include any mention of the resident's non-compliance with oxygen therapy. Interviews with various staff members revealed that the resident frequently complained of shortness of breath and requested her oxygen to be increased. Staff members reported that they were not allowed to adjust the oxygen levels and had observed the resident adjusting it herself. Despite these observations, the care plan was not updated to reflect the resident's behavior, and no additional measures were taken to ensure compliance with the physician's orders. The facility's policy required care plans to be reviewed and revised as needed, but this was not done in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Creston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creston Specialty Care | 1.9 mi | ★★★★★ | 2 | 0 |
| Lenox Care Center | 16.2 mi | ★★★★★ | 6 | 0 |
| Greenfield Rehabilitation & Health Care Center | 17.5 mi | ★★★★★ | 2 | 0 |
| Corning Specialty Care | 20.3 mi | ★★★★★ | 9 | 0 |
| Clearview Home | 24.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Accura Healthcare Of Creston.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.