Creston Specialty Care

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was working to manage the stock medications and get consistency with physician orders and medications received to decrease the risk of wrong medications provided. On 10/9/25 at 1:35 PM the DON provided a container of cranberry 500 that was in the medication cart and stated she was unable to confirm whether previous dates of cranberry were provided at the 450mg. or 500 mg., but did concur that cranberry 450 had been provided on this date.The facility's policy, Administering Medications, dated 4/19, revealed medications were administered in accordance with prescriber orders. The document provided that the individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time and right route of administration before providing the medication.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Creston Specialty Care

1001 Cottonwood Drive Creston, IA 50801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

call light on. At 7:22 AM observed Resident #3 sitting on the edge of the bed and saying someone please help. At 7:26 AM Staff C, CNA, went into the resident's room and the call light was shut off. The call light was on for 22 minutes. A continuous observation on 10/9/25 began at 10:46 AM noting Resident #4's call light was on with auditory beeping heard. Observed several staff standing at the nurses station. The resident's call light went off at 10:50 AM with no staff going in the room. Resident #4 stated the call light had been on for longer than 15 minutes. The resident acknowledged earlier in the day she had called out for help as she needed to use the bathroom and no one had answered her call light. The resident stated the call light had just been on and turned off herself and had a family member assist her as had incontinence episode waiting for staff. The family member confirmed light had been on and staff did not come to assist prior to the incontinence episode. On 10/8/25 at 4:12 PM Staff A, CNA, stated she worked both AM (6-2) and PM (2-10) shifts. The staff stated there had been times where the facility was shorter on staff on the PM shift with there being 2-3 staff present. The staff acknowledged when there were fewer staff it was more difficult to answer call lights in less than 15 minutes. On 10/8/25 at 4:31 PM Staff B, Licensed Practical Nurse (LPN), stated call lights can be on for a long period of time. The staff stated a call light on longer than 15 minutes was long. Staff B stated call lights were on longer than 15 minutes on the 2-10 shift. The staff stated there were several residents who required more assistance and there were not always enough staff present to assist them. On 10/9/25 at 11:08 AM Staff C stated it was difficult at times answering call lights in less than 15 minutes. On 10/9/25 at 11:17 AM the Director of Nursing (DON) she expected call lights to be answered as soon as possible. The DON acknowledged the standard answer is usually 15 minutes but sometimes at meals or just after lights may be longer due to multiple residents needing things at the same time. When asked about a 22 minute call light, the DON and Assistant Director of Nursing (ADON) agreed that would be a little longer than they would want. When provided with the knowledge of the resident calling out for help, they concurred that would not be something they would want to happen. The DON and ADON further agreed that they did not like that a resident turned a call light off when they were tired of waiting for staff and asked for a family member to assist them. The DON and ADON acknowledged that residents reporting incontinence episodes due to waiting for assistance was not the best scenario.On 10/9/25 at 1:25 PM the Administrator stated she would like call lights answered as soon as possible preferably within 15 minutes but knows that may not be happening. The Administrator acknowledged staffing had been a concern as the facility had hired several CNAs that were younger and still in high school. The Administrator stated with the younger staff it has been difficult getting them to work for their 2-10 shifts and their inability to use lifts without additional assistance from other staff. The Administrator stated her administrative staff (DON, ADON and herself) have been trying to help with answering call lights and attending to resident needs.The facility's Answering the Call Light Policy, dated 3/2, revealed the purpose was to ensure a timely response to the resident's needs and requests. The facility's Dignity Policy, dated 2/21, disclosed demeaning practices and standards of care that compromise dignity were prohibited with the example of promptly responding to a resident's request for toileting assistance.

Event ID:

Facility ID:

If continuation sheet