Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canyon Creek Post-acute during CMS and state inspections, most recent first.
A resident with osteoarthritis, obesity, and a care plan requiring mechanical lift transfers was being moved from a wheelchair to bed using a Hoyer lift when staff used a sling that appeared too small and had not been inspected for wear as required by the lift manual. During the transfer, a sling loop/strap broke, causing the resident to fall to the floor and strike the lift base, resulting in a shin laceration, severe pain, and the need for hospital treatment with staples. An LVN confirmed the sling was broken, and the DON later acknowledged that checking the sling prior to use, as outlined in the equipment manual, could have prevented the incident.
A resident with intact cognition fell to the floor during a Hoyer lift transfer when a sling loop/strap broke, resulting in a deep leg laceration that required ER treatment with staples and pain rated 10/10. An LVN documented the resident’s report of being dropped, confirmed the sling was broken, administered Norco, and arranged transfer to an acute hospital. The DON and Administrator both acknowledged awareness of the fall and recognized that falls and injuries related to Hoyer lift use are unusual occurrences, yet they did not report the incident to the State Agency, contrary to facility policy requiring timely reporting of unusual occurrences affecting residents’ health, safety, and welfare.
The facility failed to complete annual MDS assessments within the required timeframe for three residents, due to staffing challenges and an influx of admissions and discharges. The MDS Coordinator cited the absence of a full-time assistant and a social worker as contributing factors. The DON and Administrator were aware of the issue and expected timely completion of assessments.
The facility failed to complete quarterly MDS assessments within the required timeframe for three residents, due to staffing challenges and an increase in admissions and discharges. The MDS Coordinator cited the lack of a consistent assistant and a social worker as contributing factors. The DON was aware of the delays, and the Administrator expected compliance with timely completion and transmission of assessments.
A facility failed to complete a significant change in status assessment (SCSA) MDS for a resident admitted to hospice services. The resident had a history of liver cirrhosis, hepatitis C, and other conditions. Despite the requirement for an SCSA MDS, it was incomplete due to staffing transitions and a backlog in the MDS department. Interviews with staff revealed unfamiliarity with MDS processes and acknowledgment of the backlog issue.
A facility failed to update a resident's care plan to reflect the discontinuation of an antipsychotic medication and did not address the resident's behavior of placing soiled briefs in drawers, leading to room odor. Staff interviews revealed the resident occasionally refused toileting assistance, and the care plan lacked documentation of these behaviors, contrary to facility policy.
A resident with a history of encephalopathy and brain hemorrhage did not receive prescribed podiatry treatment due to the facility's failure to transcribe and implement the orders. The orders, which included applying antibiotic ointment to the resident's toe, were flagged in the paper chart but not entered into the electronic health record. Staff interviews revealed a lack of awareness and a breakdown in the process of handling physician orders.
The facility failed to meet room size requirements in two resident rooms, providing only 77 sq ft per resident instead of the required 80 sq ft. Despite this, residents and staff reported no issues with care provision or space. The deficiency was confirmed through measurements and interviews.
A resident did not receive scheduled showers during a two-week stay, despite being at high risk for functional decline. Interviews revealed inconsistencies in documentation and communication regarding the resident's refusal of showers.
Failure to Safely Use Hoyer Lift Sling Resulting in Resident Fall and Injury
Penalty
Summary
A resident who was cognitively intact and had diagnoses including bilateral osteoarthritis of the knees and obesity, with care plans indicating the need for a mechanical lift for transfers and assistance with activities of daily living due to fall risk, was unsafely transferred from a wheelchair to a bed using a Hoyer lift. During this transfer, staff used a sling that the CNA later described as appearing too small for the resident’s body size, chosen because it was the sling available at the time. While the resident was being transferred, one of the sling’s loops/straps broke, causing the resident to fall directly to the floor and strike the base of the Hoyer lift. Following the fall, the resident was found sitting on the floor between the base of the Hoyer lift with visible bleeding from a laceration on the left shin and reported severe pain rated 10 out of 10, requiring pain medication. The LVN who responded confirmed that the sling was broken, and the resident was transferred to an acute care hospital, where staples were applied to close the laceration. The DON later stated that the fall could have been avoidable if staff had checked the slings, such as for loose threads, prior to use. The Hoyer lift manual’s maintenance safety inspection checklist specified that sling attachments should be checked each time they are used and that sling material should be inspected for wear, indicating that required pre-use inspection of the sling did not occur as specified.
Failure to Report Hoyer Lift Fall With Injury as Unusual Occurrence
Penalty
Summary
Facility staff failed to report an unusual occurrence to the State Agency after a resident fell during a Hoyer lift transfer and sustained an injury requiring hospital treatment. The resident, who had a BIMS score of 15/15 indicating normal cognition, reported that a few months prior he fell out of the Hoyer lift while being transferred from wheelchair to bed when a strap of the sling broke, causing him to land on the floor and suffer a deep cut on his leg that required staples in the emergency room. Progress notes from the date of the incident documented that the resident stated he had been dropped, complained of 10/10 pain, was given Norco, and was sent to an acute hospital for further evaluation. The LVN who assessed the resident confirmed that the sling was broken. The DON acknowledged awareness of the fall related to the broken loop of the Hoyer lift sling but stated the incident was not reported to the California Department of Public Health because it did not occur to her that it was an unusual occurrence requiring reporting, as the cause of the fall was known. The Administrator similarly stated that it is unusual for a resident to fall or have injuries related to Hoyer lift use and that such unusual occurrences are reportable, but he did not report this fall because the facility was focused on the cause of the fall and managing the resident’s injuries. This inaction was inconsistent with the facility’s Unusual Occurrence Reporting policy, which requires reporting incidents affecting residents’ health, safety, and welfare to appropriate agencies by telephone within 24 hours and submission of a written report within 48 hours.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14 calendar days following the Assessment Reference Date (ARD) for three residents. Resident #14, diagnosed with unspecified dementia with behavioral disturbance, had an annual MDS with an ARD of 08/19/2024, but the assessment was completed on 10/25/2024, missing the deadline of 09/02/2024. Resident #27, with a diagnosis of cerebral palsy, had an ARD of 08/07/2024, but the assessment was completed on 09/27/2024, past the due date of 08/21/2024. Resident #29, diagnosed with a benign neoplasm of the cerebral meninges, had an ARD of 08/15/2024, with the assessment completed on 09/17/2024, missing the deadline of 08/29/2024. The MDS Coordinator attributed the delays to staffing challenges, including the lack of a consistent full-time assistant and the absence of a social worker in July, which led to sections of the assessments falling behind. Additionally, an influx of admissions and discharges further strained the ability to complete assessments on time. The Director of Nursing acknowledged awareness of the late assessments and mentioned that quality assurance performance improvement meetings were held monthly to discuss such issues. Despite multiple team members contributing to the MDS assessments, the MDS Coordinator was ultimately responsible for their timely completion. The Administrator also expressed an expectation for compliance with regulations and timely completion and transmission of assessments.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required 14 calendar days following the Assessment Reference Day (ARD) for three residents. Resident #13, who was admitted in 2012 with a diagnosis of paraplegia, had an MDS assessment with an ARD of September 3, 2024, but it was not completed until October 10, 2024, missing the deadline of September 17, 2024. Resident #16, admitted in 2014 with Alzheimer's disease, had an MDS assessment with an ARD of August 13, 2024, completed on October 25, 2024, past the due date of August 27, 2024. Resident #22, admitted in 2024 with metabolic encephalopathy, had an MDS assessment with an ARD of September 12, 2024, completed on October 25, 2024, missing the deadline of September 26, 2024. The MDS Coordinator attributed the delays to staffing challenges, including the lack of a consistent full-time assistant and the absence of a social worker in July, which contributed to the backlog. Additionally, an increase in admissions and discharges further strained the facility's ability to complete assessments on time. The Director of Nursing acknowledged awareness of the late assessments and mentioned that quality assurance performance improvement meetings were held monthly to discuss these issues. Despite daily MDS audits by medical records staff, the responsibility for final completion rested with the MDS Coordinator. The Administrator expressed an expectation for compliance with regulations and timely completion and transmission of assessments.
Failure to Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for a resident who was reviewed for hospice services. The resident, who had a medical history including cirrhosis of the liver, chronic viral hepatitis C, hepatic encephalopathy, protein-calorie malnutrition, and was receiving palliative care, was admitted to hospice services. Despite this, the SCSA MDS was not completed as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. The MDS Coordinator acknowledged that the SCSA MDS was opened but incomplete because an MDS nurse had not finished a section of the MDS. Interviews with facility staff, including the Social Service Supervisor, MDS Coordinator, Director of Nursing, and Administrator, revealed a lack of completion of the MDS assessments. The Social Service Supervisor admitted to being new and unfamiliar with identifying open MDS assessments, while the MDS Coordinator and Director of Nursing confirmed the requirement for an SCSA MDS when a resident is admitted to hospice services. The Administrator noted transitions in the MDS department had led to a backlog of assessments, contributing to the deficiency.
Failure to Update Resident Care Plan and Address Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, identified as Resident #167, who was admitted with a medical history including vascular dementia, benign prostatic hyperplasia, alcohol dependence, and other brain disorders. The care plan was not updated to reflect the discontinuation of quetiapine, an antipsychotic medication, which was no longer prescribed to the resident. Both the MDS Coordinator and the Director of Nursing acknowledged that the care plan should have been updated to exclude the use of the medication once it was discontinued. Additionally, the care plan did not address the resident's behavior of placing soiled incontinence briefs in drawers, refusing assistance with toileting, or the need to keep the resident's clothes in the laundry room to prevent odor. Interviews with various staff members, including CNAs and nurses, revealed that the resident was occasionally incontinent and required reminders to change briefs. The resident's behavior of storing soiled briefs in drawers led to an odor in the room, and staff had to frequently wash the resident's clothes to maintain cleanliness. The MDS Coordinator and the Director of Nursing both stated that the care plan should include target behaviors and reasons for those behaviors. The care plan should have been updated to reflect the resident's refusal of care and the specific behaviors related to incontinence. The Administrator also confirmed that behaviors should be included in the resident's care plan, indicating a lapse in the facility's adherence to its policy on comprehensive person-centered care planning.
Failure to Transcribe and Implement Podiatry Orders
Penalty
Summary
The facility failed to transcribe and carry out treatment orders for a resident, identified as Resident #42, who was admitted with a medical history of encephalopathy and non-traumatic intracerebral hemorrhage. The resident's care plan included a focus on preventing pressure ulcers and skin breakdown, with specific interventions to administer treatment as ordered. However, during an observation, it was found that a Physician's Order form with handwritten podiatry orders dated 10/01/2024 was flagged in the resident's paper chart but not transcribed into the electronic health record. The orders included applying triple antibiotic ointment to the left big toe and covering it with a bandage twice daily for 10 days. Interviews with facility staff revealed a lack of awareness and a breakdown in the process of transcribing and implementing the podiatry orders. Licensed Vocational Nurse (LVN) #4 and Registered Nurse (RN) #2 were unaware of the orders, and the Director of Nursing (DON) stated that the paper charts should be checked every shift to ensure orders are carried out. The Administrator noted that the physician should communicate new orders to the nurses, who should verify them. The facility's policy on Medication and Treatment Orders did not provide guidance on transcribing and carrying out written physician orders, contributing to the oversight.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents' rooms met the minimum size requirements as specified in their policy and federal and state regulations. Specifically, two rooms were identified where the total floor area was 154 square feet, accommodating two beds, which resulted in only 77 square feet per resident, falling short of the required 80 square feet per resident in double rooms. This deficiency was confirmed through a Client Accommodations Analysis document and direct measurements by the Maintenance Director. Despite the deficiency, observations indicated that residents were able to move freely, and staff could provide care without impediment. Interviews with residents and staff revealed that the room size did not hinder the provision of care or resident satisfaction. Residents expressed contentment with their space and storage, and staff, including a CNA and an RN, reported no issues in delivering care due to room size. The Director of Nursing and the Administrator acknowledged the importance of meeting room size requirements for resident comfort and care, yet the deficiency persisted in the two identified rooms.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers according to the scheduled plan. The resident, who was admitted to the facility and stayed for over two weeks, received only one shower during this period. The Minimum Data Set (MDS) assessment indicated that the resident needed setup or clean-up assistance for showers. The Activities of Daily Living (ADL) Care plan also highlighted that the resident had a self-care performance deficit and was at high risk for decline in functional limitations and contractures. Despite this, the resident did not receive the scheduled showers on multiple occasions, and there was a lack of documentation explaining the resident's refusal or any interventions taken to address it. Interviews with the Licensed Vocational Nurse (LVN), Certified Nurse Assistant (CNA), and Director of Nursing (DON) revealed inconsistencies in the documentation and communication process regarding the resident's refusal of showers. The DON confirmed that the resident was scheduled to receive showers every Monday and Thursday during the evening shift but did not receive them on the scheduled dates. The facility's policy and procedure for bathing and showering emphasized the importance of cleanliness, comfort, and skin condition observation, but these guidelines were not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 839 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Castro Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sage Post Acute | 0.3 mi | ★★★★★ | 1 | 0 |
| Hayward Hills Health Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Hayward Gardens Post Acute | 0.5 mi | ★★★★★ | 13 | 0 |
| Baywood Court Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Vista Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Canyon Creek Post-acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.