Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Creston Specialty Care during CMS and state inspections, most recent first.
An unlocked medication cart was found at the nurses' station with no staff present while residents were nearby in the dining/living area. The cart contained stock meds, prescribed meds for multiple residents, and other medications and supplies. An LPN later identified herself as the nurse assigned to the cart and stated she should have locked it before walking away. Facility leadership stated carts must be locked when not in use, and the policy required carts to be securely locked when out of the nurse's view.
Pureed Diet Menu Items Not Served: Seven residents ordered pureed diets were served lunch without the pureed wheat rolls listed on the approved menu. The cook verified the menu, pureed the broccoli and chicken, but forgot to puree the rolls, and all seven pureed trays were served without them. The CDM and Administrator confirmed the menu should be followed.
Food was served at temperatures below what residents expected and below the facility’s stated standard. Several cognitively intact residents reported warm foods were sometimes served cold or cooler than desired, and one resident said food lacked taste. During an observed breakfast delivery, hot items measured 118 degrees and 115 degrees after the tray was delayed and then delivered to the resident. The CDM and Administrator stated food delivered to residents should be at or above 135 degrees, and the policy required hot foods to be hot and cold foods to be cold.
Food Storage and Labeling Deficiencies: Surveyors observed multiple uncovered, unlabeled, and undated food items stored in the refrigerator, including trays with small plates and pudding-like substance, an unlabeled bag in a cereal bin, an undated bag of cheddar cheese, and unlabeled bags of green leafy items. An LPN/cook told the CDM the trays were not labeled at the start of the survey tour, and the CDM and Administrator acknowledged that stored food should be labeled. The facility policy required opened containers to be dated and sealed or covered during storage.
A resident with TBI, stroke, one-sided weakness, and a right leg fracture was observed asleep in bed without the ordered leg immobilizer in place, even though the physician’s order and care plan required it to remain on while in bed and overnight. Staff reported the resident did not like the brace, said no to wearing it, and the refusal was not communicated to the nurse; the MAR/TAR also did not include the immobilizer for monitoring.
Wheelchair Not Locked During Mechanical Lift Transfer: A resident with moderately impaired cognition, schizophrenia, anxiety, depression, muscle weakness, and unsteadiness on feet was dependent for transfers and used a wheelchair. Staff used a 2-person mechanical lift to transfer the resident from the wheelchair to the bed, but the wheelchair was observed unlocked during the transfer. The LPN and CMA later acknowledged the wheelchair should have been locked, and the DON stated wheelchairs should be locked during resident transfers.
A resident with multiple chronic conditions was not administered medications according to physician orders, resulting in possible double dosing of Apixaban due to improper handling of short stock medication cards and the administration of an incorrect dosage of cranberry concentrate. The resident experienced gross hematuria and mouth swelling, prompting medical evaluation. Staff interviews and record reviews confirmed deviations from medication administration protocols, including failure to verify correct dosages and improper use of medication cards.
Multiple residents experienced prolonged wait times for toileting and transfer assistance due to insufficient nursing staff, with call lights often left unanswered for over 15 minutes. Residents reported episodes of incontinence and emotional distress, and staff interviews confirmed that short staffing, especially on afternoon and evening shifts, contributed to these delays. Facility leadership acknowledged the issue, and observations documented staff and administrators walking past active call lights without responding.
Five residents who experienced a significant change in condition by enrolling in hospice care did not have their Comprehensive MDS Assessments completed and transmitted within the required 14-day period, with delays ranging from 18 to 25 days. The facility lacked a specific policy for MDS timing and relied on the RAI manual.
A resident with multiple chronic conditions and intact cognition was not properly offered the COVID-19 vaccine, as evidenced by a lack of signatures on the declination form and the resident's statement that she would have accepted the vaccine if offered. The DON confirmed the absence of required documentation, and facility policy mandates both education and documentation for vaccine offers.
A resident with severe cognitive impairment and full dependence on staff for wheelchair mobility was repeatedly denied assistance to leave her room, despite multiple requests. Staff locked her wheelchair brakes and did not attempt alternative interventions as outlined in her care plan, resulting in the resident being left calling for help until meal service. Interviews with staff and family confirmed awareness of the need to support resident choice and try various interventions, but these were not consistently implemented.
A resident with moderate cognitive impairment and multiple diagnoses experienced frequent pain that interfered with therapy. Despite having physician orders for Oxycodone based on a pain scale, the resident received only one tablet on eight occasions when their pain was rated between 6 and 10, instead of the prescribed two tablets. The facility's medication administration policy required adherence to prescriber orders, but the resident's pain management was not aligned with these orders.
A resident with moderate cognitive impairment and a history of falls experienced three falls over three months due to staff not following safety precautions during transfers. The staff failed to consistently use a gait belt, leading to increased pain and the need for more intensive pain management and assistance. The resident's mobility was significantly affected, requiring a two-person assist for transfers and increased reliance on a wheelchair.
A cook at the facility was observed handling ready-to-eat food with gloved hands instead of using tongs during breakfast service, contrary to FDA guidelines and facility policy. The Certified Dietary Manager intervened, noting the improper practice, which was due to a misunderstanding by the cook regarding sanitary food handling procedures.
The facility failed to protect resident information from unauthorized access, affecting five residents. A document with personal health information was observed on a medication cart, and an LPN confirmed it was a communication sheet. The facility's confidentiality policy requires safeguarding resident privacy, but the DON acknowledged that such sheets should not be left visible.
The facility failed to manage Legionella risk and ensure proper hand hygiene. The Maintenance Supervisor did not document the flushing of secondary showers, contrary to the Legionella Water Management Policy. An LPN did not perform hand hygiene while treating a resident with MASD, risking cross-contamination. A CNA also failed to perform hand hygiene while managing a resident's catheter bag. The DON confirmed that hand hygiene should be performed at specific times, as per policy.
A resident with stage II pressure ulcers was left with a trash bag on their bed and uncovered legs after a dressing change by an LPN. The resident, who was cognitively intact, expressed dissatisfaction with the care, stating that staff often left him uncovered. A CMA later addressed the issue by removing the trash and covering the resident. The DON confirmed that facility policy requires staff to ensure residents' comfort after care procedures.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. An LPN administered the wrong medication to a resident due to not checking the medication bottle properly and the prescribed medication not being stocked. The facility's policy requires three checks to ensure correct administration, which were not followed.
Unlocked Medication Cart Left Unsecured at Nurses' Station
Penalty
Summary
The facility failed to properly secure and store medications to minimize loss or access for 1 of 3 medication carts. During continuous observation, an unlocked treatment cart was found at the nurses' station with no staff present while 6 residents were seated in the nearby living/dining area. The cart contained stock medications in the top right drawer, prescribed medications for 12 residents in the second right drawer, prescribed medications for 9 residents in the third right drawer, and liquid laxative, inhalers, nebulizer solution, antacids, and cough syrup in the bottom right drawer. The top left drawer contained scissors and a pill cutter, the second left drawer was locked, and the third left drawer contained lancets. At 3:43 PM, the Administrator approached the open medication cart and asked where the nurse was. An LPN then came to the nurses' station, confirmed the cart was unlocked by opening a drawer, stated it was not her medication cart, and locked and secured it. Later, another LPN identified herself as the nurse assigned to that cart since 6:00 AM and stated she should have locked the medication cart before walking away. The Interim DON stated staff know medication carts must be locked when not in use and that education had been provided, and the Regional Director of Clinical Services stated medication carts are expected to be locked when not in use. The facility's policy stated medication carts must be securely locked at all times when out of the nurse's view and locked and parked at the nurses' station when not being used.
Pureed Diet Menu Items Not Served
Penalty
Summary
The facility failed to serve all menu items to seven residents who were ordered pureed diets. During a lunch meal observation, the cook reviewed the diet sheet, verified the menu items to be served, and stated there were seven residents prescribed pureed diets. She pureed eight servings of broccoli and chicken but did not puree the wheat rolls. During the continuous lunch service observation, all seven pureed diets were served without pureed wheat rolls. A menu review later showed that one wheat roll was included in each pureed diet on the approved menu. The cook stated she forgot to include the dinner roll in the pureed diets during preparation and service, and the CDM asked whether the roll had been added to the other pureed items, to which the cook replied no. The Administrator stated the menu should be followed.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 4 of 8 residents reviewed: Resident #5, Resident #8, Resident #14, and Resident #23. Resident #5, who had a BIMS of 15, stated that warm food was occasionally served cold and that he would like it warm, but he did not ask staff to rewarm it because he thought they would do so. Resident #8, who had a BIMS of 15, stated the food had no taste and was served cool once in a while. Resident #14, who had a BIMS of 13, stated she mostly ate soup at dinner and that the soup was not as warm as she would like; she also stated lunch was not always as hot as she would like and that she never asked staff to warm it because she thought they would. Resident #23, who had a BIMS of 15, stated the food was frequently served cooler than she would like and was cold sometimes, and she also did not ask staff to heat it because she thought they would if needed. An observation of breakfast tray delivery on the hall showed a resident’s tray was taken back to the end of the hall dining room, then later delivered after the resident was assisted to the table. When the sample tray reached the kitchen for a temperature check, the cream of wheat measured 118 degrees and the scrambled eggs measured 115 degrees. The CDM stated the temperatures should have been higher when the resident received the meal and said she would like to see food delivered at or above 135 degrees. The Administrator stated the policy documented that food delivered to the resident should be 135 degrees or above, and the facility policy also directed staff to ensure hot foods are hot, cold foods are cold, and that the resident is ready to receive the meal.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to date and label previously opened food packages and failed to properly store food in the freezer and dry goods storage room. During an initial kitchen tour on 6/28/2026, surveyors observed four serving trays with multiple uncovered, unlabeled, and undated small plates containing square items and multiple small bowls of pudding-like substance stored in the refrigerator. Surveyors also found an unlabeled bag of small, irregularly oval shaped items in a bin labeled cereal, an undated previously accessed bag of mild cheddar cheese in the walk-in refrigerator, and two unlabeled resealable bags of green leafy items dated 6/23 in the walk-in refrigerator. Staff H told the CDM that the four trays were not labeled at the beginning of the survey tour, and the CDM replied that they should have been. The Administrator later stated that stored food should be labeled. A policy titled Food Receiving and Storage revised [DATE] indicated opened containers must be dated and sealed or covered during storage.
Failure to Maintain Ordered Leg Immobilizer
Penalty
Summary
The facility failed to follow a physician’s order for Resident #56 by not keeping the right leg immobilizer in place while the resident was in bed and overnight. The resident’s MDS dated 6/25/26 showed a BIMS score of 13 out of 15 and listed diagnoses including traumatic brain injury, stroke, one-sided weakness, and a right arm fracture. The physician’s order dated 6/22/26 directed that the right leg immobilizer remain in place when the resident was in bed and overnight, and could be removed only when the resident was up ambulating and working with PT. The care plan and nursing note also directed that the immobilizer be worn at rest. During observations on 6/28/26 and 6/29/26, the resident was seen asleep in bed without the immobilizer on his right leg, and the immobilizer was observed lying on the dresser. Staff K, a CMA, stated CMAs and CNAs could apply or remove assistive devices after specialized training from PT, and Staff L, a CNA, stated the resident did not have it on when working with PT and that the CMA said it was okay to leave off. Staff K later stated the resident did not like the brace, verbally said no, and she did not notify the nurse of the refusal. The June 2026 MAR, TAR, and supplemental documentation did not include the immobilizer for staff monitoring, and Staff M, an LPN, stated the order did not transition to the area where refusals could be documented. The DON stated the immobilizer needed to be on while the resident was at rest.
Wheelchair Not Locked During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a wheelchair was locked during a mechanical lift transfer for Resident #40, who had a BIMS score of 12 out of 15 indicating moderately impaired cognition and diagnoses including anxiety, depression, schizophrenia, muscle weakness, and unsteadiness on feet. The resident’s MDS showed dependence with all ADLs and mobility except for setup assistance with eating and moderate assistance with oral hygiene, and she used a wheelchair for mobility. Her care plan directed staff to use a 2-person mechanical lift with a sling for transfers. During an observed transfer from the wheelchair to the bed, Staff G, an LPN, and Staff J, a CMA, used the mechanical lift while the wheelchair was observed unlocked. Staff J later stated wheelchairs should be locked during mechanical lift transfers and noted the wheelchair was unlocked after the transfer, and Staff G stated they forgot to lock it but acknowledged it should have been locked. The DON also stated wheelchairs should be locked during resident transfers, and the facility policy directed staff to position the wheelchair and lock the wheels when transferring a resident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide services that met professional standards for one resident by not following physician orders for medication administration. The resident, who had diagnoses including atrial fibrillation, anemia, heart failure, hypertension, and respiratory failure, was prescribed Apixaban (an anticoagulant) and cranberry concentrate for UTI prevention. The Medication Administration Record (MAR) and facility documentation revealed discrepancies in the administration of Apixaban, with evidence suggesting the resident may have received double doses on two separate days due to improper handling of short stock medication cards. Staff did not consistently use the calendar date system for dispensing medications, resulting in the potential for duplicate dosing, which could not be definitively confirmed or ruled out by the facility. The resident experienced gross hematuria (blood in the urine) and was subsequently evaluated by a provider, who suspected the bleeding was caused by extra doses of Apixaban. The medication was held as a result, and the bleeding stopped. The resident later developed mouth swelling and pain, prompting a transfer to the emergency department, where no further significant findings were reported except for mouth pain. Interviews with staff confirmed the presence of two medication cards for Apixaban and missing doses from both, as well as a lack of adherence to the prescribed method for dispensing short stock medications. Additionally, the facility failed to provide the correct dosage of cranberry concentrate as ordered by the physician. The resident was given 450 mg instead of the prescribed 500 mg, and this discrepancy was acknowledged by both the administering nurse and the DON. The facility's policy required medications to be administered in accordance with prescriber orders, including verifying the right medication and dosage, but this was not followed in the cases of both Apixaban and cranberry concentrate for this resident.
Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet toileting needs for multiple residents. Observations and interviews revealed that residents experienced significant wait times, sometimes exceeding 15 minutes, for assistance with toileting and transfers. One resident, who required partial assistance for transfers and toileting, reported waiting longer than 15 minutes for help, leading to episodes of incontinence and emotional distress. Another resident, dependent on staff for all transfers and toilet hygiene, described waiting over 1.5 hours to be changed, resulting in attending activities in soiled clothing and feeling upset about personal hygiene. Continuous observations documented instances where call lights remained on for extended periods, such as a 22-minute wait, with staff and even the administrator walking past without responding. In one case, a resident had to call out for help and ultimately relied on a family member for assistance after staff failed to respond, resulting in an incontinence episode. Staff interviews confirmed that short staffing, particularly on the afternoon and evening shifts, made it difficult to answer call lights promptly, especially for residents requiring more intensive assistance. The facility's own policies emphasized the importance of timely responses to call lights and maintaining resident dignity by avoiding demeaning practices such as delayed toileting assistance. Despite these policies, both nursing and administrative staff acknowledged that call lights were often not answered within the expected timeframe, and that staffing shortages contributed to these delays. The Director of Nursing, Assistant Director of Nursing, and Administrator all recognized that residents were left waiting for assistance, sometimes resulting in incontinence and residents turning off call lights themselves after prolonged waits.
Failure to Timely Complete MDS Assessments After Significant Change
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe following a significant change in condition for five residents who enrolled in hospice care. For each resident, the Electronic Health Record and Medicare Hospice Election forms documented the date hospice services began, but the corresponding Significant Change MDS assessments were completed and dated well beyond the 14-day requirement outlined in the 2024 Resident Assessment Instrument (RAI) Manual. The delays ranged from 18 to 25 days after hospice election, exceeding the federal guidelines for timely assessment. This deficiency was identified through clinical record review and staff interviews, which confirmed that the facility did not have a policy regarding MDS Assessments and relied solely on the RAI manual. The residents involved were all documented as having a significant change in condition due to enrollment in hospice care, which should have triggered a timely comprehensive assessment. The lack of timely MDS completion was observed for all five residents reviewed for MDS Assessments.
Failure to Properly Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to properly offer and document the COVID-19 vaccination for one resident who was eligible for the vaccine. The resident's vaccine record indicated a refusal of the COVID-19 vaccine, but the declination form lacked both the resident's and staff member's signatures. The resident had a BIMS score of 15, indicating intact cognition, and had multiple diagnoses including heart failure, chronic kidney disease, diabetes mellitus, seizure disorder, anxiety, depression, and asthma. The resident's medical record and progress notes documented a refusal of the vaccine, but there was no evidence that the resident was provided with education or that a proper consent or declination process was followed as required by facility policy. During an interview, the resident stated she was not offered the COVID-19 vaccine and confirmed she would have accepted it if offered, despite previously declining influenza and pneumococcal vaccines. The DON acknowledged the lack of signatures on the declination form and stated that staff use these forms to determine if a resident was asked about vaccination. Facility policy requires that residents be provided with education about vaccines and that this education be documented in the medical record, but there was no documentation that this occurred for the resident in question.
Failure to Support Resident Choice and Prevent Involuntary Seclusion
Penalty
Summary
Staff failed to support a resident's right to self-determination and choice by not assisting her in leaving her room despite multiple requests. The resident, who had severely impaired cognition and was fully dependent on staff for wheelchair mobility, was observed repeatedly calling for help to leave her room. Staff locked her wheelchair brakes, preventing her from leaving, and did not attempt other interventions as outlined in her care plan, such as providing one-on-one support or moving her to a quieter area. The resident remained in her room calling for help until she was eventually removed for lunch service. On another occasion, staff again failed to assist her, and when she managed to leave her room independently, she was returned and her wheelchair was locked again. Interviews with staff and the resident's family confirmed that staff were aware of the need to assist dependent residents in leaving their rooms upon request and to try a variety of interventions if one failed. The family member reported previous concerns about the resident being left in her room with her wheelchair locked, describing it as being treated like a prison. Staff interviews revealed inconsistent application of interventions and an acknowledgment that the resident should have been assisted. Facility policy and the Director of Nursing confirmed that residents should be supported in exercising their rights and not subjected to involuntary seclusion.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication according to physician orders for a resident with moderate cognitive impairment and multiple diagnoses, including arthritis and fractures. The resident's Minimum Data Set (MDS) indicated frequent pain that interfered with therapy, and the care plan directed staff to anticipate and respond immediately to pain complaints. The Medication Administration Record (MAR) documented orders for both scheduled and as-needed pain medications, including Oxycodone for pain rated on a scale of 1-10. However, the resident received only one tablet of Oxycodone on eight occasions when their pain was rated between 6 and 10, contrary to the physician's order to administer two tablets for pain rated in this range. The Director of Nursing confirmed that the expectation was to follow the physician's orders based on the pain scale, and any pain rated higher than five should have been treated with two tablets of Oxycodone. The facility's medication administration policy required medications to be administered according to prescriber orders and for staff to verify the right dosage before administration. Despite these policies, the resident's pain management was not aligned with the prescribed orders, leading to inadequate pain relief on multiple occasions.
Failure to Ensure Safe Transfers Leads to Multiple Falls
Penalty
Summary
The facility failed to maintain a safe environment for Resident #21, who experienced three falls over a three-month period due to staff not adhering to safety precautions during transfers. The resident, who had moderate cognitive impairment and a history of falls, required partial assistance for transfers and was supposed to be assisted with a gait belt. However, staff failed to consistently use the gait belt, leading to falls that resulted in increased pain and the need for more intensive pain management and assistance. The first incident occurred when the resident fell after using the restroom, and it was documented that the staff did not use a gait belt during the transfer. The second fall happened during a transfer to bed when a CNA momentarily let go of the gait belt to adjust the bed, causing the resident to lose balance and fall. The third fall occurred again during a transfer to bed, with staff failing to use a gait belt, resulting in further pain and discomfort for the resident. Following these incidents, the resident experienced increased pain, particularly in the left knee and hip, requiring frequent administration of pain medication and topical treatments. The resident's mobility was significantly affected, necessitating a two-person assist for transfers and increased reliance on a wheelchair. Despite the facility's policy on managing falls and fall risks, the staff did not consistently implement the required interventions to prevent falls and minimize complications.
Improper Food Handling During Breakfast Service
Penalty
Summary
During a breakfast meal service, a deficiency was observed in the facility's food handling practices. Staff A, a cook, was seen preparing breakfast trays while wearing disposable, single-use gloves. Initially, she used tongs to place biscuits on plates, but soon after, she began using her gloved hands to handle the biscuits directly. She continued to use her hands to slice biscuits, spoon gravy, and touch multiple serving utensils, steam tray covers, and bowls. This practice was repeated for several trays, indicating a failure to maintain sanitary conditions as per the FDA Food Code 2022 guidelines. The Certified Dietary Manager (CDM) noticed Staff A's actions and questioned her about the use of tongs. Staff A responded that she believed it was acceptable to touch the food with her gloved hands since she had set up the steam table while wearing gloves. This misunderstanding led to the improper handling of ready-to-eat food, which is against the facility's policy on preventing foodborne illness. The facility's policy requires that food be stored, prepared, handled, and served in a manner that minimizes the risk of foodborne illness, which was not adhered to in this instance.
Unauthorized Access to Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, affecting five residents. On June 17, 2024, a document titled 'Hall 2 Hot Chart' was observed on a medication cart, displaying personal health information for these residents. Staff H, an LPN, confirmed that the sheet on the medication cart was a communication sheet containing resident information. The facility's policy on confidentiality, revised in October 2017, mandates safeguarding personal privacy and limiting access to resident records to authorized personnel. However, the Director of Nursing acknowledged that communication sheets should not be left facing up with resident information visible.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to identify and manage areas or devices that could reduce the risk of Legionella or other waterborne pathogens. The Maintenance Supervisor admitted that while the secondary showers' water supply lines were routinely flushed, this was not documented. The facility's Legionella Water Management Policy, revised in 2017, was not followed, as evidenced by the lack of documentation for the flushing of plumbing fixtures in unused rooms. The Administrator confirmed that one of the four resident showers was not routinely used, and staff were expected to adhere to the facility's policy. In another incident, a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene while administering treatment to a resident with Moisture Associated Skin Damage (MASD). The LPN used stock ointments not dedicated for single-patient use and did not wash hands before donning gloves or after removing them. The ointment containers were exposed during treatment, leading to potential cross-contamination. The Director of Nursing (DON) stated that staff should place ointments in a medication cup and perform hand hygiene before and after treatment, as per the facility's hand hygiene policy. Additionally, a Certified Nursing Assistant (CNA) did not perform hand hygiene at the appropriate times while managing a resident's catheter bag. The CNA donned gown and gloves before entering the resident's room but did not perform hand hygiene before applying gloves. After emptying the catheter bag, the CNA removed gloves and gown without performing hand hygiene immediately. The DON confirmed that hand hygiene should be completed at the start of treatment, when gloves are visibly soiled, when removing dirty gloves, and when leaving a resident's room, as outlined in the facility's hand hygiene policy.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to uphold the dignity of a resident by leaving a trash bag with bandage wrappers on the resident's bed and not covering the resident's legs after a dressing change. The resident, who was cognitively intact with a BIMS score of 14/15, had two stage II pressure ulcers upon admission. During an observation, a Licensed Practical Nurse (LPN) placed a trash bag on the resident's bed while changing dressings on the resident's feet. After completing the procedure, the LPN left the room without removing the trash bag, replacing the resident's socks, or covering the resident's legs. The resident activated the call light shortly after the LPN left, and a Certified Medication Aide (CMA) responded. The resident requested the CMA to bring the LPN back to remove the trash and cover him properly. The CMA returned alone, removed the trash, replaced the resident's socks, and covered the resident's legs. The resident expressed dissatisfaction with the care, stating that staff often left him uncovered after personal care. The Director of Nursing (DON) confirmed that the facility's policy required staff to dispose of trash and ensure residents' comfort after care procedures.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 8%. During a medication administration observation, two errors were identified out of 25 opportunities. Specifically, a Licensed Practical Nurse (LPN) administered Fexofenadine Hydrochloride instead of the prescribed Fiber 500 mg to a resident. The error occurred because the LPN did not check the medication bottle properly and the Fiber medication was not stocked in the medication cart. The facility's policy on administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. The Director of Nursing confirmed that these checks should be performed during medication administration. However, the LPN failed to adhere to this policy, leading to the medication error.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 24 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
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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) |
|---|---|---|---|---|
| Accura Healthcare Of Creston | 1.9 mi | ★★★★★ | 7 | 0 |
| Lenox Care Center | 15.5 mi | ★★★★★ | 6 | 0 |
| Greenfield Rehabilitation & Health Care Center | 16.6 mi | ★★★★★ | 2 | 0 |
| Corning Specialty Care | 18.7 mi | ★★★★★ | 9 | 0 |
| Clearview Home | 25.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.