Creston Village Assisted Living And Memory Care

At 1:20pm on 03/11/2025, Licensing Program Analysts (LPA’s) Jeffries and Haner-Tomasko arrived unannounced to deliver the final findings to all the allegations to this complaint. LPAs also conducted a subsequent case management visit on a report not related to this complaint during the same visit. LPAs met with Administrator, Adam Bramwell, announced who they are and the reason for the visit. As to the allegations of, “Staff do not ensure that resident's incontinence needs are being met.” and “Staff do not ensure that residents are assisted with bathing. “ It was alleged that Resident 1’s (R1) hair, and clothes were covered in own fecal matter and incontinence was not regularly changed by facility staff. It was discovered through observation and interviews on 11/21/2024 LPA Jeffries conducted a physical tour of facility memory care unit. LPA observed R1’s room to be clean and free of odor. LPA also attempted to interview R1 on 11/21/2024 however R1 interview did not result in a responsRead the full finding— CDSS inspection report, March 11, 2025 · control 29-AS-20241120103550

At 9:00am on 01/23/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to issue final findings to the allegations above to this complaint as well as to conduct facility annual inspection on a separate report. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. As to the allegation of, “Staff inappropriately restrained resident.” It was alleged that an unknown date in September 2024, Staff 1 (S1), S2, and a third unidentified staff (S3) held down Resident 1 (R1). It was discovered through interviews and documentation that in interviews by Licensing Program Analyst (LPA) Jeffries, on 09/16/2025, with S1 and S2. It was discovered that R1 had had assistance with manicuring R1’s fingernails in September of 2024 by S1 and S2. Both S1 and S2 denied restraining R1 during the assistance with manicuring R1’s fingernails. S1 stated that, we both (S1 and S2) assisted R1 but no one had to restrained (R1) in doing so.” S1 did not recall who theRead the full finding— CDSS inspection report, January 23, 2025 · control 29-AS-20240912163515

At 8:45am on 12/19/2024, Licensing Program Anaylist (LPA) Jeffries arrived to the facility unannounced to issue final finding to the allegations to this complaint. LPA met with Administrator Adam Bramwell, annoucned who he is and the reason for the visit. As to the allegations of, “Facility failed to notify responsible party/physician in residents change of condition.”, “Facility did not observed residents change of condition.”, “Facility did not follow terms of admission agreement.”, and “Facility did not provided change of contract notification.” It was alleged that there was a lack of communication, and not replying to calls or emails to the family or physician’s a notification in R1’s change of condition. It was discovered through documentation and interviews of the following: On 05/15/2024, LPA Jeffries reviewed R1’s Admissions Agreement dated 02/15/2024, this Admissions Agreement was initialed and singed in all applicable notations with the following notable acknowledgements: CONRead the full finding— CDSS inspection report, December 19, 2024 · control 29-AS-20240506140046

At 9:30am on 08/29/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to deliver the final findings to all the allegation to this complaint. LPA met with facility Administrator Adam Bramwell, announed who he is and the reason for the visit. As to the allegation of, “Resident sexually abused while in care.” It was alleged that Reporting Party (RP) was told by Staff that Resident 1 (R1), had stated “He raped me”. It was discovered through interviews, observation and documentation that on 11/02/2023, LPA Jeffries attempted to conduct an interview with Resident 1 (R1). R1 was cognitively unable to answer questions of LPA when asking basic screening questions (ie: what is your name? Do you know where you are right now?), R1 did not answer. LPA noted that approximately 15 minutes after the attempted interview, R1 was yelling several profanities at staff. On 11/02/2023, LPA interviewed Wellness Director (S1). S1 stated that the facility has been aware of R1’s sRead the full finding— CDSS inspection report, August 29, 2024 · control 29-AS-20231101084515

At 9:45am on 04/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation to the allegation to this complaint. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. LPA conducted a facility tour, took photographs, made observations, collected and reviewed documents and conducted interviews. LPA issued final findings below: As to the allegation of, “Staff do not ensure resident's restrooms are clean and sanitized.” It was alleged that approximately 04/03/2024, Residents in Memory Care Units bathrooms were unsanitary and unclean. On 04/09/2024, at approximately 10:50am, Administrator Adam Bramwell and LPA Jeffries conducted a visual inspection of all 14 bathrooms in the memory care unit. LPA photographed and noted that 13 of 14 bathrooms were clean and in good working order. LPA noted that the one bathroom in question was cleaned, however the floor was sticky. This was discovered to noRead the full finding— CDSS inspection report, April 9, 2024 · control 29-AS-20240404095309

At 9:45am on 04/09/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA met with Administrator, Adam Bramwell, announced who he is and the reason for the visit. As to the allegations of, “Facility staff billed resident for services not rendered.” It was alleged that R1 was billed for services not rendered during the months of July through August 2023. It was discovered through interviews on 10/26/2023, LPA Jeffries conducted a phone interview of Family Member 1 (F1) that Resident 1 (R1) had been billed for the month of June for two different levels of care (Level 1 and level 2), also had not been provided access to at least 2 staff assisted showers per week after 06/01/2023, and a refund due of medication that was discontinued by R1’s Physician, that had been recorded after the Physicians discontinued order. On 10/26/2023, LPA Jeffries interviewed facility staff 2 (S2) who presented documentRead the full finding— CDSS inspection report, April 9, 2024 · control 29-AS-20231023105727

At 9:57am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final finding to this complaint and in a separate report conduct the annual facility inspection. LPA met with Interim Administrator, Adam Bramwell announced who he is and the reason for the visit. As to the allegation of, “Staff do not respond to call bell in a timely manner.” It was discovered through documentation and interviews that R1’s call bell record from this facility indicated that between the days of April 8th, 2023, through June 8th, 2023, R1’s call pendent was pressed 87 times, during that time there were a total of 5963 total calls at the facility from an average of 60 residents who have call pendants. R1’s 87 calls represent less than .02% of total calls during that time period. Of those 87 calls, 42 calls (48% of R1’s calls) took longer than 10 minutes for facility staff to respond. This included the following call time responses: one call response time of overRead the full finding— CDSS inspection report, February 15, 2024 · control 29-AS-20230601115306

At 9:01am on 06/08/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA, met with Administrator Cheryl Marsh, announced who he was and the reason for the visit. As to the allegation of, “Facility overcharging residents in care.” It was discovered through interviews, documentation, and observation that the facility has two independent financial oversight programs that need to communicate with each other to ultimately resolve resident monthly billing. In interviews with Administrator and S1 it was discovered that when a new resident service is added (for example, Level of Care increase) the facilities billing system will add that service to that month’s billing, and it will not prorate or remove the replaced service until the next billing cycle, thus charging a full month for both services. The following billing cycle will resolve the added service by crediting and/or prorating the added service and theRead the full finding— CDSS inspection report, June 8, 2023 · control 29-AS-20230221102902

At 10:00am on 05/25/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA, met with Administrator Cheryl Marsh, announced who he was and the reason for the visit. As to the allegation of, “Resident physically assaulted another resident in care.” It was discovered by documentation, and interviews that on 10/22/2022, R1 was sitting with peer at a dining table at approximately 1:00pm, when staff turned their back to table, R1 was sitting with R2, R2 struck R1 in the area of R1’s chest. S2 and S3 separated the residents, assessed for injuries, none were noted on R1 or R2. Out of precaution facility contacted 911. EMT arrived and accessed R1 and found no need for transport due to no injury. Facility contacted R1’s Physician, Responsible Party, Community Care Licensing, Ombudsman and submitted Unusual Incident Report (LIC 624 (4/99) on 10/28/2022. CONTINUED on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, May 24, 2023 · control 29-AS-20221025100703

At 10:00am on 05/25/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA, met with Administrator Cheryl Marsh, announced who he was and the reason for the visit. As to the allegation of, “Facility overcharging residents.” It was discovered through interviews, documentation, and observation that the facility has two independent financial oversight programs that need to communicate with each other to ultimately resolve resident monthly billing. In interviews with Administrator and S1 it was discovered that when a new resident service is added the facilities billing system will add that service to that month’s billing, and it will not prorate or remove the replaced service until the next billing cycle. The following billing cycle will resolve the added service by crediting and/or prorating the added service and the service it replaced (if applicable). This billing resolution can take up to two billing cyRead the full finding— CDSS inspection report, May 24, 2023 · control 29-AS-20221109110234

At 10:30am on 04/21/2023, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to issue final findings to the allegation above to this complaint. LPA introduced himself and announced the reason for the visit. LPA met with Administrator, Cheryl Marsh and explained the reason for the visit. As to the allegation of "Facility did not meet resident’s needs due to insufficient staffing." It was alleged due to a lack of staffing, residents were not showered for multiple days, left a resident in bed for 24 hours, and was not assisted with toileting. LPA reviewed the staff schedule and Resident 1 (R1)’s needs. It was discovered through interviews, and documentation that R1 was non-ambulatory and required two person lift to ambulate. Shower schedule documentation showed showers for R1 competed on 04/02/22, 04/05/22, 04/08/22, 04/09/22, 04/10/22, 04/12/22, 04/16/22, 04/19/22, and 04/23/22. CONTINUED on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, April 21, 2023 · control 29-AS-20220421141830

At 10:00am on 03/25/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to deliver final findings to the allegations above to this complaint. LPA met with Maintenance Director/ Brain Lloyd announced who he was and the reason for the visit. As to the allegation of, “Facility requires staff to work during illness.” It was discovered through interviews and documentation that facility staff were required, upon initial entry to the facility for each shift, to screen for symptom of illness, known recent contacts of ill persons, alternate work environments, and temperature, and sign and notate any of the possible symptoms of illness. LPA reviewed each staff self-screening, with staff signatures for the months of October 2021 through January 2022 and there were no staff that entered the facility with symptoms or relative conditions related to possible symptoms as indicated from the self-screening sign-in documentation. Interviews of Staff S2 through S6 did not reveal any requireRead the full finding— CDSS inspection report, March 25, 2023 · control 29-AS-20220112095629