Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Creekside Healthcare Center during CMS and state inspections, most recent first.
A resident’s RP made multiple documented attempts to obtain the resident’s medical records, including certified mail, email to the SSD, phone calls, and a faxed request with an authorization form, death certificate, and ID addressed to Medical Records. The SSD acknowledged overlooking the RP’s email, and the MRD reported being unaware of the earlier mail and fax requests, stating that faxes could have been mixed with other documents. The facility’s policy required records to be made available within 24 hours, but the records were not released until a law firm later submitted a request on the RP’s behalf.
Three residents with mental health diagnoses were not properly screened or referred for required PASRR Level II evaluations. PASRR Level I screenings failed to accurately identify serious mental illness or the need for further evaluation, and necessary referrals to the state mental authority were not made, as confirmed by the DON during interviews and record reviews.
A laundry staff member was observed transferring soiled linen to the washer while only wearing gloves and not a gown, contrary to facility policy. The staff member reported never being instructed to use a gown, and the supervisor confirmed inconsistent gown use among laundry staff, despite policy requiring PPE to prevent cross-contamination.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility failed to maintain effective pest control, leading to flies and gnats in resident care units and a dead kitten outside a resident's window for over 22 hours. Residents reported feeling unsanitary, and staff confirmed awareness of the issue. Despite using sprays and traps, the pest problem persisted, and the facility's pest control policy was not adequately followed.
The facility exceeded the acceptable medication error rate, reaching 9.38%, due to three errors. A resident did not receive Amlodipine for high blood pressure because it was unavailable. Additionally, two residents with diabetes received insulin injections without following the manufacturer's recommended administration technique, potentially affecting the effectiveness of the doses.
The facility failed to maintain the correct temperature in a medication refrigerator, which was consistently below the recommended range. This refrigerator contained insulin and other medications that require specific storage conditions. Staff members were either unaware of the correct temperature range or did not take action to address the issue, potentially compromising medication efficacy.
The facility failed to ensure that the arbitration agreement was explained to residents or their representatives, affecting three residents with cognitive impairments. Representatives were unaware of the agreement's inclusion in admission documents and were not informed about their rights to rescind it. The Admissions Assistant and Director did not provide adequate information, potentially violating residents' rights to informed decision-making.
A resident experienced pain and limited range of motion due to unaddressed right forearm swelling. Despite the resident's complaints and visible symptoms, the facility failed to accurately assess and report the condition to the physician. The care plan required daily monitoring and physician notification, which were not adhered to.
A resident with severe cognitive impairment fell from a Hoyer lift during a transfer, resulting in a scalp laceration and hematoma. The incident occurred as a CNA operated the lift and an LVN adjusted the wheelchair, neither preventing the fall. The LVN lacked training on the lift, contrary to facility policy requiring two-person assistance and adherence to manufacturer's instructions.
A resident with hypertension did not receive their prescribed amlodipine due to an empty medication pack, which was supposed to be supplied by the pharmacy. The LVN discovered the issue during a medication pass and noted that the medication was delivered later but not administered. Facility policies require timely administration and notification of the pharmacy and physician if medications are unavailable.
A resident was prescribed quetiapine without an appropriate indication or proper behavior monitoring. The resident, diagnosed with unspecified dementia, was given the medication for noncompliance with the care plan, which was not a valid reason. Observations showed no unsafe behaviors, and the facility failed to verify the resident's history of auditory hallucinations and wandering until after the medication was administered, risking untreated psychosocial distress.
A resident with Alzheimer's and other medical conditions fell during a transfer assisted by an LVN and a CNA, resulting in a head injury. The facility failed to report the incident to the CDPH as required by regulations, potentially delaying investigation and affecting resident safety.
A resident with COPD and acute bronchospasm informed the facility staff about his high sensitivity to scents, but the facility failed to create or update a care plan to address this issue. Despite multiple complaints, the resident continued to receive care from staff wearing cologne or smoke, leading to frustration and a respiratory incident requiring treatment.
Failure to Timely Provide Requested Medical Records to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a deceased resident’s medical records to the resident’s Responsible Party (RP), as required by regulation and facility policy. The resident was admitted and later discharged due to death, and after the resident’s death the RP initiated multiple attempts to obtain the resident’s medical records. The RP first submitted a medical records request by certified mail, which tracking showed was delivered, and also sent an email to the facility’s Social Services Director (SSD) asking for assistance with the process and what documents were needed. The RP reported making multiple phone calls without connecting with the appropriate staff. When the RP did not receive a response, she sent a follow-up request and supporting documents via fax to the facility’s Medical Records Department, addressed to the Medical Records staff by name, and obtained a fax confirmation report showing successful transmission. The faxed packet included a cover letter referencing the earlier certified mail request and asking the facility to confirm receipt, along with a completed authorization for release of information, a copy of the resident’s death certificate, and a copy of the RP’s government-issued ID. Despite these documented efforts, the facility did not respond to the RP’s direct requests. Interviews and record review showed that the Medical Records Director (MRD) and the Administrator were not aware of the RP’s earlier certified mail and fax requests and only processed a later request submitted by a law firm on behalf of the RP, at which point the records were released. The MRD stated that the facility receives many faxes on two fax machines and the RP’s faxed request could have been mixed with other documents. The SSD acknowledged receiving an email from the RP requesting help with obtaining records and stated she must have overlooked it, noting that “it seems this one slipped by.” The MRD confirmed that, per facility policy, medical records requests should be fulfilled within 24 hours (excluding holidays and weekends), and acknowledged that the RP did not receive the requested records in a timely manner, contrary to the policy and regulatory requirements for resident access to records.
Failure to Accurately Screen and Refer Residents for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that three of four sampled residents were properly screened and referred for Preadmission Screening and Resident Review (PASRR) Level II evaluations as required. For one resident with diagnoses including post-traumatic stress disorder, anxiety disorder, and depression, the PASRR Level I screening completed prior to admission did not accurately identify the presence of a serious mental illness, and no referral for a Level II evaluation was made. The Director of Nursing (DON) confirmed that the facility's process involved the Interdisciplinary Team (IDT) reviewing PASRRs upon admission, but in this case, the PASRR was not accurately completed or followed up. Another resident with diagnoses of psychotic disorder, anxiety, and depression also had a PASRR Level I that failed to accurately reflect their mental health conditions, and the DON acknowledged the screening was not accurate. A third resident, admitted with depression and schizophrenia, had a PASRR Level I that indicated the need for a Level II mental health evaluation and referral, but the resident was not rescreened or referred to the appropriate state mental authority. The facility's policy required designated staff to review PASRRs from acute hospitals and determine if follow-up, such as a Level II referral, was needed. These failures were identified through interviews and record reviews, and the DON confirmed the deficiencies in the PASRR screening and referral process for all three residents.
Failure to Ensure Proper PPE Use During Soiled Linen Handling
Penalty
Summary
A deficiency was identified when a laundry staff member was observed handling soiled linen from a hamper to a washer while only wearing gloves and not a gown, as required by facility policy. The staff member stated she had never been instructed to use a gown during this process and acknowledged that wearing a gown could help prevent the spread of infection. The Laundry Staff Supervisor confirmed that a gown should always be worn when handling soiled linen, but noted that compliance among laundry staff was inconsistent, with some staff choosing not to wear gowns due to discomfort. Facility policy reviewed indicated that personal protective equipment, including gowns, should be used when handling soiled linen to prevent cross-contamination.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Ineffective Pest Control and Dead Animal Neglect
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in three resident care units. Observations revealed multiple instances of flies in residents' rooms, including on food and personal items, causing residents to feel unsanitary and distressed. A dead kitten was found outside a resident's window for over 22 hours, attracting more flies and creating a foul smell that permeated the resident's room. Despite residents' complaints and the use of chemical sprays, the source of the pest problem was not addressed. Interviews with staff, including a CNA, housekeeper, and the Maintenance Director, confirmed awareness of the pest issue and the presence of the dead kitten. The Maintenance Director was unaware of the dead animal, and the facility's pest control measures, such as fly traps and sprays, were ineffective. The Director of Nursing acknowledged the risk posed by pests, and the Administrator admitted awareness of the issue since February 2024, yet no records of dead animals or effective pest control actions were found in the maintenance log. The facility's pest control policy required reporting and documentation of pest sightings, which was not adequately followed.
Medication Error Rate Exceeds 5% Due to Unavailability and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 9.38% during a medication pass. Three medication errors were identified among six residents. The first error involved a resident with high blood pressure, chronic kidney disease, and dementia, who did not receive their prescribed Amlodipine due to its unavailability. The medication was supposed to be supplied by the pharmacy, but the bubble pack was empty, and the medication was not administered even after it was delivered later in the day. The second and third errors involved the improper administration of insulin to two residents with diabetes. In both cases, the nurses failed to follow the manufacturer's recommendations for insulin administration. One resident received Semglee insulin without the needle being held in place for the recommended 10 seconds, potentially affecting the dose's effectiveness. Similarly, another resident received Humulin R insulin without the needle being held for the recommended five seconds. These actions could have impacted the effectiveness of the insulin doses administered.
Improper Medication Storage Due to Refrigerator Temperature Issues
Penalty
Summary
The facility failed to store medications and biologicals safely when the temperature in one of the medication refrigerators was consistently out of the recommended range. Observations revealed that the temperature in medication refrigerator 2 was below the normal range, recorded at 32 degrees Fahrenheit and even dropping to 29 degrees Fahrenheit. This refrigerator contained emergency medication kits and various insulin vials, which according to the manufacturer's instructions, should be stored at temperatures between 36 and 46 degrees Fahrenheit. Despite the temperature log indicating out-of-range temperatures on multiple occasions, staff members, including RN 2 and RN 4, were either unaware of the correct temperature range or did not take appropriate action to address the issue. Interviews with staff members, including RN 3 and RN 4, revealed a lack of understanding of the potential impact of incorrect storage temperatures on medication efficacy. The Director of Nursing acknowledged that medications could freeze if stored below the recommended range, which could compromise their integrity and effectiveness. The facility's policy on medication storage, which aligns with the manufacturer's recommendations, was not adhered to, as evidenced by the repeated failure to maintain the correct refrigerator temperature. This oversight had the potential to compromise the safety and effectiveness of medications administered to residents.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a manner that was understood by the residents or their representatives, affecting three sampled residents. Resident 49, who had moderate cognitive impairment, was represented by RR 1. RR 1 was unaware that an arbitration agreement was part of the admission documents signed and was not informed about the option to rescind the agreement within 30 days. Similarly, Resident 65, also with moderate cognitive impairment, signed the arbitration agreement without receiving a copy of the Dispute Resolution Program information or understanding its purpose. The Admissions Assistant, who facilitated the signing, was unable to explain the arbitration agreement or confirm what information was provided to the residents or their representatives. Resident 68, with severe cognitive impairment, was represented by RR 2, who signed the arbitration agreement without understanding its implications. RR 2 was not informed about the arbitration agreement during the admission process and only learned about it during the interview. The Admissions Director confirmed that the arbitration agreement was included in the admission packet, but there was no evidence that the residents or their representatives were adequately informed about the agreement or their rights regarding it. This lack of communication and understanding potentially violated the residents' rights to make informed decisions about their healthcare and welfare.
Failure to Assess and Address Resident's Swelling and Pain
Penalty
Summary
The facility failed to accurately assess a resident, identified as Resident 322, for right forearm swelling, which resulted in the resident experiencing pain and limited range of motion. Upon admission, the resident's data collection indicated swelling in the right upper extremity. However, during an observation and interview, the resident reported that the swelling and pain had persisted for weeks without any intervention from the facility. The resident expressed significant distress over the lack of treatment. Certified Nursing Assistant (CNA) 1 confirmed the resident's complaints of pain and swelling, which were reported to Registered Nurse (RN) 1. Despite this, RN 1 did not inform the resident's physician about the pain and edema noted. A review of the Treatment Administration Record and Nursing Progress Notes showed no documentation of swelling or pain on the previous day, indicating an inaccurate assessment. The resident's care plan required daily monitoring for pain and skin breakdown, with a directive to notify the physician once a day, which was not followed.
Resident Falls from Hoyer Lift Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and proper transfer procedures, resulting in a resident falling from a Hoyer lift. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and dementia, who required assistance from two or more helpers for activities of daily living. During a transfer from bed to wheelchair, the resident fell from the lift, sustaining a superficial scalp laceration and hematoma. The fall occurred while a CNA was operating the lift and an LVN was adjusting the wheelchair, neither of whom could prevent the fall. Interviews revealed that the LVN had not received training on the Hoyer lift, despite the facility's policy requiring at least two caregivers for safe transfers. The Director of Staff Development confirmed that all staff, including licensed nurses, are trained on the use of the Hoyer lift upon hire, but it was not a requirement for LNs. The facility's policy emphasized following manufacturer's instructions and ensuring two-person assistance during transfers. The lack of proper training and adherence to policy contributed to the incident, as the LVN was not adequately prepared to assist in the transfer process.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services when a resident's medication, amlodipine, was not available and not administered as ordered. The resident, who was admitted in December 2019 with diagnoses including hypertension, chronic kidney disease, and dementia, did not receive their prescribed dose of amlodipine, a medication used to treat high blood pressure. During a medication pass observation, an LVN discovered that the bubble pack for amlodipine was empty and stated that the medication was supposed to be supplied by the pharmacy. The LVN mentioned that they usually request refills in advance when there are only a few doses remaining. The physician's order for the resident indicated a daily administration of amlodipine 10 mg, with instructions to hold the medication if the systolic blood pressure was less than 100. However, the medication was not available during the scheduled administration time, and the EMAR for amlodipine was not signed off on the day in question. The LVN later confirmed that the medication was delivered by the pharmacy later that day but was not administered. The facility's policy and procedure for medication pass guidelines and pharmaceutical services require that medications be administered in a safe and timely manner, and if unavailable, the pharmacy should be notified for delivery, and the physician should be informed for further orders or recommendations.
Inappropriate Use of Antipsychotic Medication Without Proper Indication or Monitoring
Penalty
Summary
The facility failed to ensure that a resident received quetiapine, an antipsychotic medication, with an appropriate indication for use or proper behavior monitoring. The resident was admitted with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Despite this, the resident was prescribed quetiapine for psychosis manifested by noncompliance with the plan of care, which was not an appropriate indication. The facility did not document any attempts by the resident to refuse or deny care, and the Director of Nursing acknowledged that noncompliance was not a valid reason for the medication's use. Observations and interviews revealed that the resident did not exhibit unsafe behaviors or mood disturbances, and the resident's behavior was not adequately monitored as per the facility's policy. The resident's representative indicated that the resident had a history of auditory hallucinations and wandering, which led to the initial prescription of quetiapine before admission. However, the facility failed to verify this information until after the medication was administered. This lack of appropriate indication and monitoring placed the resident at risk of experiencing untreated psychosocial distress.
Failure to Report Resident Fall Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting a fall incident involving a resident to the California Department of Public Health (CDPH) and other appropriate agencies, as required by federal or state regulations. This oversight had the potential to delay the investigation and affect the health, safety, or welfare of residents. The incident involved a resident with multiple medical diagnoses, including Alzheimer's disease, dementia, aphasia, chronic kidney disease, sensorineural hearing loss, and high blood pressure. The incident occurred when the resident was being assisted by an LVN and a CNA to transfer from bed to a wheelchair using a Hoyer lift. During the transfer, the resident accidentally slid down to the floor, resulting in a laceration and a bump on the back of her head, necessitating a transfer to the hospital via 911. The facility's policy, titled Unusual Occurrence Reporting, mandates reporting of such incidents, but this was not followed, leading to the deficiency noted in the report.
Failure to Address Resident's Sensitivity to Scents
Penalty
Summary
The facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after an identified concern for a resident with high sensitivity to scents. Despite the resident informing the staff and administrator about his sensitivity to fragrances and scents upon admission, the facility did not create or update a care plan to address this issue. The resident, who had multiple diagnoses including acute bronchospasm and Chronic Obstructive Pulmonary Disease (COPD), continued to receive care from staff wearing cologne or smoke, leading to frustration and a respiratory incident requiring treatment. During an interview, the administrator acknowledged being aware of the resident's sensitivity to scents but did not take the complaint seriously due to the absence of allergy history in the medical records. A review of the resident's progress notes and grievance/complaint report confirmed multiple complaints about the issue, yet no care plan was made. The facility's policy and employee handbook also indicated the need to limit the use of strong perfumes and colognes, which was not adhered to in this case.
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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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Nursing homes near San Pablo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vale Healthcare Center | 0.1 mi | ★★★★★ | 5 | 0 |
| San Pablo Healthcare & Wellness Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Richmond Post Acute Care | 0.9 mi | ★★★★★ | 0 | 0 |
| Greenridge Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Shields Richmond Nursing Center | 2.3 mi | ★★★★★ | 3 | 0 |
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