Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Creswell Post Acute during CMS and state inspections, most recent first.
Ice machine drain lacked the required air gap in a janitor closet on the North Hall. The Maintenance Director did not know what an air gap was and did not view the drain placement as a problem, while the ice machine was observed draining into a dirty sink with trash and reddish discoloration where it dripped into the basin.
Improper Sanitizing and Storage of Resident Care Equipment: An LPN used an alcohol pad to clean a glucometer instead of the facility’s designated Super Sani-Cloth Wipes, and bedpans were repeatedly observed uncovered or only partially bagged on the floor in a shared restroom between resident rooms. The DNS confirmed the glucometer cleaning product was not appropriate and that the bedpan storage observed was not the proper process when equipment was not in use.
Failure to Assess Self-Administration of Bedside Medication: A resident with DM was observed with Senokot on the overbed table and stated a provider had told him/her to take it a couple times a day. The record had no order or assessment for self-administration, and an LPN later confirmed there was no approval for bedside medication. The resident also stated he/she had taken some of the Senokot during the stay.
Failure to complete baseline care plans within 48 hours of admission. Two residents had no timely baseline care plan or complete Kardex information to guide care needs. One resident admitted with DM and subarachnoid hemorrhage had no care plan, and staff confirmed it was missing. Another resident admitted with a Stage 4 sacral pressure ulcer and osteomyelitis had a Kardex that only covered catheter care, while the record lacked a baseline care plan for wound care, pain management, IV abx, or other identified needs.
A facility failed to develop comprehensive care plans for residents with depression, hospice needs, and chronic diarrhea. One resident had severe depression, was receiving scheduled psychotropic meds, and had psychosocial concerns, but the care plan lacked resident-centered interventions for mood or anxiety. Another resident was on hospice but had no hospice care plan. A third resident had ongoing diarrhea with multiple loose stools, PRN anti-diarrheal use, and stool incontinence, yet the care plan did not fully address the condition.
Two residents who needed help with bathing did not receive bathing as scheduled. One resident with chronic pain syndrome and moderate cognitive impairment reported staff rushed showers and did not clean thoroughly, while records showed missed baths, no follow-up after refusals, and no make-up bathing documented. Another resident with diabetes and extensive bathing needs reported being bathed only once since admission, and records showed scheduled showers were not completed. Staff said bathing could be missed when agency or limited staffing affected the assignment.
Delayed Tracheostomy Care Orders: A resident with a tracheostomy, dysphonia, dysphagia, and Barrett's esophagus did not have clear trach care orders obtained in a timely manner after admission. The discharge paperwork said trach care was to be provided as directed but lacked specific instructions, and staff later confirmed the orders were unclear and were not obtained until several days after admission. The resident was sent to the hospital when the trach cannula appeared dislodged, and the resident later reported delayed staff response for trach care needs such as gauze changes and suctioning.
Staff were not ensured to be competent before providing tracheostomy care to a resident who required suctioning and tube care. Interviews showed some nurses and an agency LPN were not trained, one nurse said she did not know how to provide trach care, and delays in suctioning occurred. An LPN reported using the wrong tube size during a trach tube change, inadvertently removing the tube, and the resident was sent to the hospital when staff could not locate the trach supplies.
A resident admitted with skin infection and wounds missed multiple doses of Rifaximin after the facility failed to obtain the medication before it ran out. The MAR and progress notes showed repeated missed doses and repeated entries that the med was on order, but there was no documentation of follow-up with the pharmacy. Staff said med pass staff were responsible for ordering before meds ran out, and the DNS said pharmacy follow-up and documentation were expected.
Failure to provide influenza and pneumococcal vaccinations for a resident with diabetes was identified during record review. The resident consented to a pneumonia vaccine, but the chart showed no evidence that an influenza vaccine was offered or that either vaccine was administered. The DNS stated the facility offered flu vaccines and that the pneumonia vaccine should have been given at the same time, but the resident did not receive them.
A resident admitted with respiratory failure consented to receive a COVID-19 vaccine, but the immunization record showed the vaccine was not given. The DNS confirmed the resident did not receive the vaccine during the facility’s COVID-19 clinic.
A resident with dementia and behavioral disturbance was found with a bruise to the left eye, and staff could not determine the cause of the injury. Although a CNA reported the bruise to an LPN, the incident was not reported to the State Survey Agency in a timely manner, resulting in non-compliance with reporting requirements.
A resident was discharged without a documented discharge plan, as required. Review of the clinical record showed the discharge plan was overdue, and neither the care plan nor care conference notes addressed the resident's discharge preferences. Staff interviews confirmed the discharge plan was not completed and revealed a lack of familiarity with the discharge planning procedure.
Two residents with complex medical needs, including a fractured femur, osteoarthritis, pressure ulcer, and chronic kidney disease, did not have their required MDS assessments completed on time. Staff confirmed that these assessments were overdue and acknowledged the delay.
A resident with dementia was involved in incidents of agitation and physical aggression, but the care plan was not updated in a timely manner to include interventions to prevent further occurrences. The care plan revision was delayed despite the identification of necessary interventions after the initial incident, as confirmed by the DON.
Two residents with chronic medical conditions and intact cognition experienced prolonged call light wait times of 40 and 47 minutes. Staff members reported being occupied with other duties or lacking communication devices, and the DON confirmed that these wait times were too long.
The facility failed to provide complete discharge summaries for three residents, omitting essential information from their most recent assessments. A resident with diabetes, another with heart failure, and a third with dementia had discharge summaries lacking details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. This was acknowledged by the DNS during an interview.
The facility failed to properly store and label medications and biologicals, as observed during audits of a treatment cart and a medication refrigerator. An open vial of Insulin Glargine was found to be over 28 days old, and an undated tuberculin vial and expired Spikevax vaccines were discovered. Staff confirmed these findings and acknowledged the need for proper labeling and disposal.
The facility failed to follow physician orders and provide timely care, resulting in deficiencies. A resident had bed rails removed without notification, another experienced delayed bowel care and inconsistent pain medication administration, and a resident consumed excess alcohol during an outing. Medication administration delays were common, with staff citing high acuity and workload as reasons. Residents expressed dissatisfaction with these delays.
A facility failed to obtain consent for an influenza vaccination for a cognitively intact resident with diabetes. The resident received the vaccine, but a review of their medical record showed no signed consent. The DNS confirmed the absence of consent, acknowledging it should have been obtained before vaccination.
The facility failed to notify emergency contacts and a physician in two cases. A resident hospitalized for abdominal issues had no emergency contacts informed, despite being cognitively intact. Another resident, post-spinal surgery, developed a lump on the back, but the physician was not notified, although the family was informed. Staff later acknowledged these communication lapses.
A resident, who was cognitively intact and had diabetes, reported that her/his cell phone was stolen, leading to a $300 replacement cost. Despite informing social services, no grievance form was completed. The staff acknowledged the need for a grievance form and investigation.
A facility failed to provide a bed hold policy to a resident during hospitalization, which is necessary to inform them of their rights to return. The resident, admitted in 2018 with delayed stomach and intestine emptying, was hospitalized multiple times without receiving the policy. Social Services staff stated that they provided the policy if present, but nursing staff were responsible after hours or on weekends. It was confirmed that the resident did not receive the policy during their hospitalizations.
A resident admitted with paralysis after spinal surgery did not have a baseline care plan that included necessary spinal precautions. The care plan was updated over a week later to include log-rolling and spinal precautions, but the resident reported staff did not follow these directions. Staff interviews revealed a lack of effective communication and documentation of the necessary precautions.
A resident with third-degree burns was discharged from an LTC facility without proper wound care training or home health support, leading to hospital readmission for infected wounds. The facility failed to ensure the resident or their roommate received necessary wound care instructions, resulting in a lack of adequate post-discharge care.
A resident with severe cognitive deficits did not receive necessary assistance with ADLs, including regular showers and nail care, as required. Observations showed the resident had dirty hair and fingernails, and documentation lacked evidence of refusal for missed bathing dates. Staff confirmed the resident should have received showers twice a week.
The facility failed to assist two residents in obtaining prescription glasses, risking impaired vision. One resident, admitted with bowel and stomach dysfunction, did not receive glasses despite a new prescription. Social Services staff were unaware of the prescription. Another resident with diabetes experienced a delay in receiving glasses after an ophthalmologist visit, with no staff follow-up recorded. Staff acknowledged the issue but had not completed the order through insurance.
A resident with a right finger contracture did not receive a necessary splint, despite assessments and referrals indicating its need. The care plan did not include the splint, and staff were unaware or had not seen the splint applied. This oversight was identified as a deficiency in the facility's care.
A facility failed to maintain a medication error rate below five percent, with two errors in 39 opportunities. A resident with chronic conditions did not receive Creon at the prescribed time, and staff failed to ensure mouth rinsing after Advair Diskus use, as per physician orders.
A resident admitted with diabetes, who was cognitively intact, signed an arbitration agreement but later did not recall doing so, citing heavy medication and lack of follow-up. The Social Service Director, responsible for explaining and managing arbitration agreements, confirmed that she did not follow up with residents after they signed, considering it a one-time task. This led to a deficiency in ensuring the resident's understanding of the agreement.
A resident with post-surgical paraplegia, who was cognitively intact, experienced a dignity-related deficiency when a CNA initially refused to change wet sheets, causing the resident frustration and fear. The CNA eventually changed the sheets after initially insisting they were not wet. The DNS confirmed that staff should honor such requests.
A resident's right to privacy was violated when a staff member at an LTC facility opened their mail without permission. The resident, who was cognitively intact and had diabetes, reported the incident, which involved a package containing supplements. Staff acknowledged the error, emphasizing that mail should be delivered unopened, and staff should only be present when residents open suspected medication packages.
A resident admitted with paralysis developed a pressure ulcer due to inconsistent implementation of a care plan aimed at preventing such injuries. Despite being at risk, the resident was not consistently turned every two hours, and education on positioning was not regularly provided. Staff acknowledged challenges in adhering to care standards, contributing to the development of a deep tissue injury.
A resident with moderate cognitive impairment and a history of alcohol use consumed more beer than the physician-ordered limit during an outing. Two staff members failed to supervise the resident adequately, allowing the resident to drink additional beers provided by a non-staff member. The resident returned to the facility with altered vital signs, and the staff did not report the excess alcohol consumption to the nurse.
Ice Machine Drain Lacked Required Air Gap
Penalty
Summary
The facility failed to ensure an ice machine had the required air gap for 1 of 2 facility ice machines reviewed for kitchen sanitation. On 1/28/26 at 10:04 AM, the Maintenance Director was observed cleaning the ice machine in the janitor closet on the North Hall and stated he did not know what an air gap was or whether the ice machine had one. He confirmed the drainpipe was located below the sink basin and did not believe this was a problem if the sink backflowed. At 10:34 AM, the ice machine was observed draining into a sink on the floor with the top of the sink extending above the bottom of the drain, resulting in no air gap between the drain and the sink. The sink contained trash, appeared dirty, and had reddish discoloration where the ice machine dripped into it. At 11:54 AM, the Administrator reviewed the ice machine and drain and stated it would be repaired.
Improper Sanitizing and Storage of Resident Care Equipment
Penalty
Summary
The facility failed to properly sanitize and store resident care equipment for 1 of 3 halls reviewed for infection control. On 1/28/26 at 11:19 AM, Staff 6 (LPN) was checking CBGs on the central hall and then moved to the south hall with one glucometer on top of the medication cart and no cleaning supplies in sight. Staff 6 stated he cleaned the glucometer with an alcohol pad and opened the drawer to point out small alcohol prep pads. Another staff member then provided Staff 6 with the purple top Super Sani-Cloth Wipes. Later that day, Staff 6 stated that before moving to the south hall he had checked one CBG with the glucometer and cleaned it with an alcohol prep pad. At 12:46 PM, Staff 2 (DNS) stated staff were to use the purple top Super Sani-Cloth Wipes to clean the glucometer and that the alcohol prep pads were not an appropriate cleaning product. The facility also failed to properly store bedpans in the restroom shared between Rooms 15-16. On 1/27/26 at 3:00 PM, a gray plastic bedpan was observed lying uncovered on the floor beneath the sink in the shared restroom, directly on the floor. On 1/28/26 at 9:19 AM, the same restroom contained a gray plastic bedpan lying on the floor beneath the sink, uncovered and partially on top of a clear plastic bag, with part of the bedpan directly touching the floor. Staff 23 (CNA) stated bedpans were labeled with resident names and stored in plastic bags in the restroom when not being used. Staff 2 (DNS) stated the expectation was for bedpans to be labeled, cleaned after use, and stored in a closed plastic bag in the restroom when not in use. On 1/30/26 at 10:35 AM, two gray bedpans were observed stacked in the same shared restroom, with the bottom bedpan partially within a clear plastic bag but not enclosed and the top bedpan not bagged. Staff 2 observed the bedpans and confirmed this was not the proper process for storage when they were not in use.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident who wished to self-administer medication was assessed for self-administration of Senokot. Resident 21 was admitted in 1/2026 with a diagnosis of diabetes. On 1/26/26, the resident was observed with a box of Senokot on the overbed table in the room with no staff present, and stated that a medical provider had told him/her to take Senokot a couple times a day. The medical record showed no order for self-administration of Senokot and no assessment for self-administration. On 1/29/26, an LPN reviewed the record, stated there was no approval for the resident to keep medication at the bedside, and removed the Senokot from the room after confirming it was present on the overbed table. The resident stated that he/she had taken some of the Senokot during the stay. On 1/30/26, the DNS stated that residents who wished to have medication at bedside were to have an assessment, a physician order for self-administration, a care plan, and the medication stored in a lock box in the resident room.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to comprehensively complete a baseline care plan within 48 hours of admission for 3 of 3 sampled residents reviewed for care plans, placing residents at risk for unmet needs. Resident 76 was admitted with diagnoses including diabetes and subarachnoid hemorrhage, but a 1/27/26 record review found no evidence of a baseline care plan. Staff 25, a CNA, stated resident care needs were in the care plan and then stated Resident 76 did not have a care plan. Staff 3, an LPN Resident Care Manager, acknowledged Resident 76 did not have a care plan, and Staff 2, the DNS, stated it was the expectation for staff to formulate a baseline care plan for new residents at admission. Resident 77 was admitted with diagnoses including a Stage 4 pressure ulcer on the sacral region and osteomyelitis. Staff 10, a CNA, stated she read residents' care needs from the Kardex, but no Kardex existed for this new resident. Staff 11, an agency CNA, stated sometimes residents did not have a Kardex and staff would have to ask the charge nurse about care needs; the Kardex reviewed for Resident 77 only contained catheter care information. The 1/26/26 Baseline Care Plan Person-Centered Care Plan showed Resident 77 had a Stage 4 sacral pressure ulcer, required wound vac treatment, antibiotics, and had a lot of pain, and was dependent on staff, but no documentation was found showing a baseline care plan addressing the pressure ulcer, treatment, pain management, IV antibiotics, or other identified needs. Staff 12, the Regional Nurse, confirmed Resident 77's baseline care plan was not completed timely.
Incomplete Care Plans for Depression, Hospice, and Chronic Diarrhea
Penalty
Summary
The facility failed to implement comprehensive care plans for 3 of 7 sampled residents reviewed for unnecessary medications, diarrhea, and hospice. Resident 3 was admitted with diagnoses including dysphonia and depression. The hospital discharge summary showed a PHQ-9 score of 21 indicating severe depression, and the admission MDS indicated the resident was cognitively intact, had no mood disorders, and was receiving scheduled antidepressant and antipsychotic medications. The psychosocial well-being CAA noted little interest or pleasure in doing things, that the resident had significant health issues and needed a trach to support breathing, and that the resident was at risk for psychosocial issues due to lack of interest in favorite activities. A physician note documented that the resident reported feeling emotional but did not want psychotropic changes, and the interdisciplinary conference note stated the resident felt uncomfortable around others. Staff were to encourage activity participation, but the care plan did not include resident-centered interventions related to depression, anxiety, or mood. Staff later confirmed the care plan was not comprehensive. Resident 9 was admitted with diagnoses including hypertension and COPD and had been admitted to hospice in 6/2025, but the 6/27/25 care plan contained no hospice care plan. Staff confirmed the resident had been on hospice since 6/2025 and acknowledged hospice should have been included in the comprehensive care plan. Resident 32 was admitted with diagnoses including urinary retention and protein malnutrition. Prior care plans addressed bowel incontinence risk and later skin impairment risk related to mixed incontinence and occasional diarrhea, but the 11/11/25 quarterly MDS indicated the resident was always continent of bowel. Physician follow-up notes documented a history of chronic diarrhea, the bowel task showed 19 episodes of loose diarrhea over a one-month period, and the resident reported frequent diarrhea for the past year and requested evaluation by a gastroenterologist. Staff described ongoing diarrhea and constipation, multiple diarrhea episodes in a day, and frequent requests for PRN anti-diarrheal medication. During observation, the resident was lying in bed with a stool-stained brief, and staff and the roommate described frequent diarrhea and prolonged time spent in the bathroom. Staff later confirmed the care plan was not comprehensive.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide bathing for 2 sampled residents who were unable to bathe independently. One resident was admitted with chronic pain syndrome, had a BIMS score of 9 indicating moderate cognitive impairment, and was dependent for bathing. That resident stated feeling not as clean as desired because staff rushed through showers and did not clean the genitals thoroughly, and also stated bathing assistance was needed due to pain. The bathing schedule called for showers twice weekly, but the record showed missed scheduled baths, no documented follow-up attempts after refusals, no documented bathing on two scheduled Sundays, and no make-up bathing documented on any Saturday. The resident was observed with greasy hair and could not recall the bathing schedule. Staff reported the bathing schedule was inconsistent due to agency staff and that missed showers were expected to be re-offered or rescheduled. The second resident was admitted with diabetes, had a BIMS score of 13 indicating cognitive intactness, and required extensive assistance with bathing per the care plan. The shower schedule called for bathing on Mondays and Thursdays, but the bathing task record showed one bath completed and the scheduled showers on two other days documented as not scheduled for that shift, with no additional showers completed. The resident stated being bathed only one time since admission and said staff did not bathe them despite asking about it. The resident was observed in a hospital gown with hair appearing unwashed and uncombed, and later stated not yet being bathed that week. Staff reported that when the designated shower aide was moved to CNA duties or staffing was low, bathing could be missed, and staff were expected to offer bathing as scheduled with missed baths offered on Saturdays.
Delayed Tracheostomy Care Orders
Penalty
Summary
The facility failed to obtain physician orders for tracheostomy care in a timely manner for Resident 3, who was admitted with diagnoses including dysphonia, dysphagia, and Barrett's esophagus without dysplasia. The facility's tracheostomy care policy stated staff were to verify physician orders, and the hospital discharge orders dated 12/5/25 indicated tracheostomy care as directed but did not include specific tracheostomy instructions. The nursing admission/readmission evaluation also documented that Resident 3 required tracheostomy care. A nurse's note on 12/8/25 at 11:45 AM stated Resident 3 did not have tracheostomy care orders in place, and the tracheostomy cannula appeared dislodged from the neck opening, resulting in transfer to the hospital for evaluation and placement of the tracheostomy tube. Review of the record showed staff did not obtain tracheostomy care orders upon admission or before the resident returned from the hospital. Later observations and interviews documented that the resident's tracheostomy site gauze was slightly saturated, the resident requested assistance for gauze changes and suctioning, and response times from staff were often prolonged. Staff confirmed the discharge orders were unclear and acknowledged that tracheostomy care orders were not obtained until three days after admission.
Staff Competency Gaps in Tracheostomy Care
Penalty
Summary
The facility failed to ensure nurses and nurse aides completed the competencies needed to care for a resident with a tracheostomy before providing care. The 2025 Facility Assessment identified required staff competencies and stated that orientation included a competency checklist, with competencies evaluated annually and supplemented with additional training as needed. Resident 3 was admitted with diagnoses including dysphonia, dysphagia, and Barrett's esophagus without dysplasia, and the 12/5/25 hospital discharge orders included tracheostomy care as directed. The admission/readmission assessment also documented that Resident 3 required tracheostomy care, but no additional tracheostomy-specific care instructions were included in the discharge documentation. During the survey, Resident 3 reported requesting help for tracheostomy suctioning multiple times and experiencing extended wait times before care was provided. Staff interviews showed that not all nurses were trained to provide tracheostomy care, and one agency LPN stated she had given instructions to some nurses. The same staff member reported the resident was dependent on staff for tracheostomy care and had anxiety related to difficulty breathing, and she overheard an agency nurse say she did not know how to provide tracheostomy care. Another witness reported hearing a nurse say she did not know how to provide tracheostomy care for the resident and stated she had to provide suctioning on multiple occasions because of delays in staff response. An LPN stated he did not know how to provide tracheostomy care, had not received prior training from the facility, used the incorrect tube size during an attempted tracheostomy tube change, inadvertently removed the tube, and the resident was sent to the hospital because staff were unsure where the tracheostomy supplies were located.
Missed antibiotic doses due to delayed medication ordering
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to acquire medications, resulting in missed doses for one sampled resident. The resident was admitted in 1/2026 with diagnoses including a skin infection and wounds. On 1/6/26, the resident was prescribed oral antibiotic Rifaximin 550 mg tablets, one tablet twice daily. The 1/2026 MAR showed missed doses on 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26, and progress notes documented that the Rifaximin was on order on each of those dates. There was no documentation showing follow-up with the pharmacy to check the medication order status. Staff stated that medication staff were responsible for placing orders before medications ran out, and the DNS stated that staff were expected to follow up with the pharmacy about whether an on-hand substitute was acceptable or whether the pharmacy could satellite the medication, with communication to the pharmacy documented.
Failure to Provide Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide influenza and pneumococcal vaccines for 1 of 5 sampled residents reviewed for immunizations. Resident 6 was admitted in 9/2022 with a diagnosis of diabetes. An 8/19/25 informed consent showed the resident consented to receive a pneumonia vaccine, but the medical record contained no indication that a current influenza vaccine was offered. The immunization record also showed no evidence that Resident 6 received either a pneumonia vaccine or an influenza vaccine. During an interview on 1/30/26 at 1:59 PM, the DNS stated the facility offered influenza vaccines in 9/2025 and 10/2025 and that it should have been offered to Resident 6, and stated the pneumonia vaccine should have been administered at the same time as the influenza vaccine, but the resident did not receive the vaccines.
Failure to Provide COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide a COVID-19 vaccine for 1 of 5 sampled residents reviewed for immunizations. Resident 13, who was admitted in 2018 with a diagnosis of respiratory failure, had an informed consent dated 11/6/25 showing consent to receive a COVID-19 vaccine, but the immunization record showed the resident did not receive the vaccine. On 1/30/26 at 1:59 PM, Staff 2, the DNS, confirmed that Resident 13 did not receive the COVID-19 vaccine during the facility's 11/2025 COVID-19 clinic.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report in a timely manner an allegation of injury of unknown source for one resident with behavioral disturbance and dementia. The resident was found with a bruise to the left eye, and staff were unable to determine how the injury occurred, nor could the resident explain the incident. A CNA observed the bruise and reported it to an LPN, but the incident was not reported to the State Survey Agency as required. The Director of Nursing confirmed that the incident met the criteria for non-compliance due to the delay in reporting.
Failure to Provide Discharge Plan for Resident
Penalty
Summary
The facility failed to provide a discharge plan for one of three residents reviewed for discharge planning. Review of the clinical record for this resident showed no evidence of a discharge plan, and a notification in the record indicated the discharge plan was overdue by 16 days. The resident's care plan did not address discharge preferences, and care conference notes also lacked documentation of a discharge plan. During interviews, the Social Services Coordinator acknowledged that the discharge plan should have been completed, and the Director of Nursing Services stated she was not familiar with the discharge planning procedure, noting that it was the responsibility of Social Services to complete the discharge plan.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely Minimum Data Set (MDS) assessments for two residents. One resident, admitted with a fractured femur and osteoarthritis, had an admission MDS assessment that was still in progress and overdue by 15 days. Another resident, admitted with a pressure ulcer and chronic kidney disease, had an annual MDS assessment that was also in progress and overdue by 15 days. Staff interviews confirmed that the MDS Coordinator was behind on assessments and that MDS assessments are expected to be completed in a timely manner.
Failure to Timely Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to update the care plan for a resident with dementia following a reported incident of agitation and subsequent physical aggression. The resident was admitted with a diagnosis of dementia and was involved in an incident where the care plan was supposed to be revised to include an intervention to keep the resident further than an arm's length away from others when agitated. Although this intervention was identified after a facility reported incident, the care plan was not updated until after a second incident of physical aggression occurred. The Director of Nursing Services acknowledged that the care plan should have been updated within five days of the initial incident but was not revised in a timely manner.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of two residents during random observations. One resident, admitted with chronic kidney disease and epilepsy and assessed as cognitively intact, experienced a call light wait time of 47 minutes, as observed on the call light monitor. The resident confirmed that call light wait times were sometimes long, and a CNA reported being occupied with another resident's care during the delay. The CNA also noted that staff no longer had access to communication devices previously used to coordinate care. The Director of Nursing Services acknowledged that the wait time was too long. Another resident, admitted with anxiety and chronic pain and also cognitively intact, had a call light wait time of 40 minutes. The CNA assigned to this resident was working in the dining room during the delay, and the Director of Nursing Services confirmed this wait time was also excessive.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete comprehensive discharge summaries for three residents, which included a final summary of their status at the time of discharge. This deficiency was identified during interviews and record reviews. Resident 2, admitted in July 2024 with diabetes, had a discharge summary dated August 28, 2024, that did not include all necessary items consistent with their most recent comprehensive assessment. Missing information included details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. Similarly, Resident 4, admitted in July 2024 with heart failure, and Resident 5, admitted in June 2018 with dementia, also had incomplete discharge summaries. The discharge summaries for these residents, dated September 4, 2024, and August 26, 2024, respectively, lacked comprehensive details from their most recent assessments. These omissions were acknowledged by Staff 1 (DNS) during an interview on October 9, 2024, confirming that the discharge summaries did not provide a complete summary of the residents' final status upon discharge.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, which was identified during an audit of the South Hall treatment cart and the medication and biologicals refrigerator. An open vial of Insulin Glargine was found in the treatment cart with a date indicating it was over 28 days old, which should have been discarded. This was confirmed by a registered nurse (RN) during the audit. Additionally, an audit of the medication and biologicals refrigerator revealed an open and undated multi-dose vial of tuberculin solution and multiple closed vials of Spikevax (COVID-19 vaccine) with an expired date. A licensed practical nurse (LPN) verified the absence of an open date on the tuberculin vial and disposed of it in the sharps container. The expired Spikevax vials were acknowledged, with the facility awaiting a pharmacy exchange for viable vaccines. The RNCM stated that the expectation was for all medications to have an open date and for expired medications to be discarded appropriately.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents, leading to multiple deficiencies. One resident, admitted with cancer, had their bed rails removed without family notification, which were not transferred to a new bed. Another resident, admitted with paralysis, experienced delayed bowel care and inconsistent administration of pain medication, with staff failing to document or provide additional interventions when initial treatments were ineffective. A resident with alcohol use issues consumed more alcohol than permitted during an outing, as staff failed to supervise adequately and did not report the excess consumption to the facility upon return. Another resident received the wrong medication due to a discrepancy in the Medication Administration Record and Narcotics Log, although no adverse effects were reported. Additionally, several residents experienced delays in receiving their scheduled medications, with staff citing high resident acuity and workload as reasons for the delays. The report highlights systemic issues in medication administration and care delivery, with multiple instances of late or missed medications for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and epilepsy. Staff acknowledged the challenges in meeting scheduled medication times, and residents expressed dissatisfaction with the delays, indicating a need for improved processes and staffing to ensure timely and accurate care.
Failure to Obtain Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain consent for an influenza vaccination for one resident, who was part of a sample of five residents reviewed for immunizations. The resident, admitted in October 2023 with a diagnosis of diabetes, was cognitively intact as indicated by a quarterly MDS assessment. A review of the resident's immunization record showed that the influenza vaccine was administered in December 2023. However, upon reviewing the medical record, there was no evidence of a signed consent for the vaccine. The Director of Nursing Services confirmed the absence of the signed consent and acknowledged that consent should have been obtained prior to administering the vaccine.
Failure to Notify Emergency Contacts and Physician
Penalty
Summary
The facility failed to notify a resident's emergency contacts and physician in two separate incidents, leading to deficiencies in communication and care. Resident 18, who was admitted to the facility in 2010 with a diagnosis of delayed stomach and bowel emptying, was transported to the hospital for abdominal pain, nausea, vomiting, and uncontrolled diarrhea. Despite being cognitively intact, as indicated by a quarterly MDS, Resident 18's emergency contacts were not informed of the hospitalization, as confirmed by both the resident and Staff 3 (RNCM). In another incident, Resident 47, who was admitted in July 2024 with paralysis following spinal surgery, experienced a change in condition when a small lump was identified above the surgical incision after reporting a popping sensation in the back. Although the family was informed and planned to contact the spinal surgeon, the facility staff did not notify the resident's physician about the lump. This oversight was acknowledged by Staff 2 (DNS) and Staff 3 (RNCM) during an assessment of the resident's spine.
Failure to Initiate Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance process for a resident who was cognitively intact and had been admitted with diagnoses including diabetes. The resident reported that her/his cell phone was stolen a couple of months ago, resulting in a personal expense of $300 to replace it. Despite informing the facility's social services staff about the incident, no grievance form was filled out by either the resident or the staff member. The staff member acknowledged that this situation should have been treated as a grievance and required a formal grievance form and investigation.
Failure to Provide Bed Hold Policy During Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received a bed hold policy during hospitalization, which is a requirement to inform residents of their rights to return to the facility. This deficiency was identified for one of the two sampled residents reviewed for hospitalization. Resident 18, who was admitted to the facility in 2018 with a diagnosis of delayed emptying of the stomach and intestines, was hospitalized on multiple occasions between October 2023 and August 2024. However, the progress notes did not indicate that Resident 18 or their emergency contacts were provided with a bed hold policy during these hospitalizations. On August 29, 2024, Staff 4 from Social Services stated that if she was present when a resident was discharged to the hospital, she ensured the resident or their representative received a bed hold policy. However, if the discharge occurred after hours or on weekends, the nursing staff was responsible for providing the policy. It was confirmed that Resident 18 was not provided with bed hold policies at the time of their hospitalizations.
Failure to Implement Baseline Care Plan for Spinal Precautions
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a diagnosis of paralysis after spinal surgery. The baseline care plan, initiated several days after admission, did not include necessary precautions such as log-rolling and spinal precautions to prevent twisting of the spine. These precautions were only added to the care plan over a week later, following a therapy document that indicated the need for two staff to assist with bed mobility and ensure no leg movement. Despite the care plan update, the resident reported that staff did not follow the therapy directions for turning. Interviews with staff revealed that the necessary spinal precautions were not communicated effectively, as they were not included in the initial baseline care plan. Staff members acknowledged that the information was typically provided verbally by the nurse upon admission and added to the care plan within 24 hours, but in this case, the precautions were not documented until much later.
Failure in Safe Discharge Planning for Resident with Burn Wounds
Penalty
Summary
The facility failed to ensure safe discharge planning services for a resident who was admitted with third-degree burns to the left chest, abdomen, and thigh. Upon discharge, the resident was sent home with orders for home health and daily wound care. However, the home health services did not visit the resident before they were readmitted to the hospital due to concerns of wound infection and inability to self-care. The resident's burn wounds were found to be infected, requiring intravenous antibiotics. Interviews with facility staff revealed that although home health was ordered, they did not have time to see the resident before the hospital readmission. Additionally, there was no evidence of wound care training provided to the resident or their roommate, who was supposed to assist with wound care. The resident reported being discharged by mistake, as they were unable to perform wound care independently and had no family or friends to assist. The facility did not discuss or train the resident on wound care prior to discharge.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with severe cognitive deficits, placing the resident at risk for unmet needs. The resident, admitted with a diagnosis of diabetes, was observed with dirty hair and jagged fingernails, indicating a lack of proper hygiene care. Documentation revealed that the resident did not receive scheduled showers or bathing on multiple occasions, with no evidence of refusal documented for several missed dates. Staff acknowledged the resident should have received showers twice a week and confirmed the absence of documentation for refusals on specific dates.
Failure to Assist Residents in Obtaining Prescription Glasses
Penalty
Summary
The facility failed to assist two residents in obtaining prescription glasses, which placed them at risk for impaired vision. Resident 18, who was admitted in October 2018 with bowel and stomach dysfunction, reported blurred distant vision during an eye exam in June 2024 and received a new prescription. Despite being cognitively intact, Resident 18 stated in August 2024 that they had not received the new glasses. Staff members from Social Services were unaware of the new prescription and did not have the after-visit summary, indicating a lack of follow-up on the resident's vision care needs. Similarly, Resident 3, admitted in March 2023 with diabetes, experienced a delay in receiving prescription glasses. Progress notes from July 2024 indicated that Resident 3 inquired about the status of their glasses, but there was no evidence of staff follow-up in the clinical record. In August 2024, Resident 3 reported seeing an ophthalmologist six weeks prior and was told the glasses would take about three weeks to arrive, yet they had not been received. Staff acknowledged awareness of the appointment and provided an invoice for the glasses dated June 2024, but the order had not been completed through the insurance provider.
Failure to Provide Necessary Splint for Resident
Penalty
Summary
The facility failed to provide a necessary splint for a resident with a right finger contracture, which was identified as a deficiency. The resident, admitted in March 2010 with a diagnosis of cancer, had an occupational therapy treatment encounter on May 9, 2024, where measurements for a right finger splint were obtained. However, the care plan last revised on July 5, 2024, did not include the requirement for a right finger splint. A physician appointment on July 24, 2024, noted the resident's right finger swelling and redness, and a referral for a finger splint was made. Despite these assessments and referrals, the resident was observed without a finger splint on August 27, 2024. Interviews with staff revealed a lack of awareness and documentation regarding the need for the splint. Staff 4, responsible for making appointments for referrals, was unaware of the need for a hand therapist or splint. Staff 15 confirmed that a splint was ordered, but it was not included in the care plan. Other staff members, including CNAs and a CMA, reported never seeing or applying a splint to the resident's finger. The RNCM acknowledged that the splint was not on the care plan, despite having helped order one.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 5.13 percent error rate. This was based on observations, interviews, and record reviews. Specifically, there were two errors in 39 medication administration opportunities. One of the errors involved a resident with chronic pancreatitis and chronic obstructive pulmonary disease, who was admitted in August 2024. The resident's physician orders included Creon to be administered three times a day with meals and Advair Diskus to be administered twice a day. On August 28, 2024, a staff member administered the resident's medications after breakfast but failed to have the resident rinse and spit after using the Advair Diskus, as required. Additionally, the Creon was not administered at the provider-ordered time of 8:00 AM.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident understood an arbitration agreement, which was a deficiency identified during a survey. Resident 47, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact according to the admission MDS, signed an arbitration agreement shortly after admission. However, the resident later stated that they did not recall signing the agreement, attributing this to being heavily medicated at the time and not receiving any follow-up regarding the agreement. The Social Service Director, responsible for admission paperwork, including arbitration agreements, confirmed that she explained the agreement and its optional nature but did not follow up with residents after they signed, considering it a one-time task. This lack of follow-up contributed to the resident's lack of understanding of the arbitration agreement.
Resident Dignity and Self-Determination Compromised
Penalty
Summary
A deficiency was identified involving the dignity and self-determination of a resident diagnosed with post-surgical procedure paraplegia, who was admitted to the facility in July 2024. The resident, who was cognitively intact, reported feeling frustrated and afraid due to interactions with a CNA regarding the changing of bed sheets. On one occasion, the resident requested the CNA to change sheets that were wet from sweat, but the CNA initially insisted the sheets were not wet and did not need changing. The resident felt compelled to argue to receive care. Eventually, the CNA left the room, returned with another CNA, and the sheets were changed. The DNS confirmed that staff should honor such requests from residents, and the resident reported feeling that it took too long for staff to return and provide the requested care.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to respect the privacy and confidentiality of a resident's personal mail. Resident 12, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact, reported that a staff member opened a package addressed to them without permission. The incident occurred when a staff member, identified as Staff 5, opened the package after hearing a sound that suggested it contained supplements or medication. This action was acknowledged by Staff 5 as a violation of the resident's rights. Further interviews revealed that Staff 14, the Activity Director, confirmed the accidental opening of the package and emphasized that all mail addressed to residents should be delivered unopened. Staff 3, an RNCM, was unaware of the incident but stated that staff should never open a resident's mail, even if it is suspected to contain medication. Instead, staff could be present when the resident opens their mail. The failure to deliver the mail unopened compromised the resident's right to privacy and confidentiality.
Failure to Prevent Pressure Ulcers in Resident with Paralysis
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident who was admitted with paralysis after spinal surgery. Upon admission, the resident did not have any pressure ulcers, and a care plan was initiated to address the risk of pressure ulcer development. However, the care plan's interventions, which included educating the resident and family on positioning requirements, were not consistently implemented. Progress notes from late July to early August indicate that the resident was assisted with turning and bed mobility, but the frequency of these actions was not documented. Additionally, there were several instances where no education was provided to the resident or family, despite the resident's reluctance to move due to incision pain. By early August, the resident developed a deep tissue injury on the sacral area, which was identified as a skin impairment with a moisture component. Interviews with staff and the resident's spouse revealed that the resident was not consistently turned every two hours, as required by standard care practices. Staff members acknowledged the challenges in adhering to the turning schedule due to time constraints and the resident's preference to remain on their back with the head of the bed elevated, which increased pressure on the coccyx region. The lack of consistent turning and education contributed to the development of the pressure ulcer.
Inadequate Supervision During Resident Outing Involving Alcohol
Penalty
Summary
The facility failed to provide adequate supervision during an outing involving alcohol for a resident with a history of alcohol use and moderate cognitive impairment. The resident was allowed to consume more alcohol than the physician-ordered limit of 12 ounces of beer. During the outing, two staff members, a Staffing Coordinator and an HR staff, were responsible for supervising the resident. However, they were unaware that the resident consumed additional beers beyond what was initially provided. The resident's condition changed upon returning to the facility, showing signs of fatigue, decreased responsiveness, and abnormal vital signs, prompting a call to EMTs. The investigation revealed that the resident consumed three and a half 12-ounce beers, exceeding the physician's order. The staff members involved did not inform the facility's nurse about the actual amount of alcohol consumed by the resident. Additionally, the staff allowed the resident to be unsupervised on the riverbank with a non-staff member, who provided the resident with more beer. This lack of supervision and communication led to a failure in ensuring the resident's safety during the outing, as evidenced by the resident's altered condition upon return.
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What surveyors actually found near you
We read the 115 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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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 Creswell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Health And Rehabilitation Of Cascadia | 7.9 mi | ★★★★★ | 5 | 0 |
| South Hills Rehabilitation Center | 8.4 mi | ★★★★★ | 6 | 0 |
| Cascade Manor | 8.4 mi | ★★★★★ | 4 | 0 |
| Hillside Heights Rehabilitation Center | 9 mi | ★★★★★ | 14 | 0 |
| Cottage Grove Post Acute | 9.2 mi | ★★★★★ | 0 | 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.