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 Creekside Post-acute during CMS and state inspections, most recent first.
A resident with chronic venous ulcers did not have a wound care order transcribed onto the TAR, as confirmed by a treatment nurse during review. This omission meant the prescribed wound care might not have been administered as ordered.
A CNA assisted a resident with repositioning an ice wrap on the knee, removed gloves, and exited the room without performing hand hygiene. The CNA acknowledged the lapse, and facility policy requires hand sanitizing after glove removal and resident contact, as confirmed by the infection preventionist.
A resident with a history of heart failure had a change in code status from Full Code to DNR, but the facility failed to promptly communicate and document this change in the EMR. During a medical emergency, staff and EMS found conflicting POLST forms, leading EMS to perform CPR based on outdated information, contrary to the resident's wishes. Staff interviews confirmed lapses in communication, documentation, and record management.
A resident admitted after a surgical amputation experienced a decline in mental status, but the nurse did not notify the physician as required, instead leaving a message in a communication binder. Additionally, a wound care order for daily dressing changes from the hospital was not transcribed into facility orders, resulting in no dressing changes for two days.
A resident with a history of a humerus fracture and muscle weakness was discharged home with a family member and a home health agency referral. However, the MDS inaccurately indicated discharge to a hospital. Interviews with staff confirmed the coding error, with expectations for accurate MDS coding expressed by the DON and Administrator.
The facility failed to ensure accurate and timely PASRR screenings for two residents. One resident's Level I screening did not reflect a diagnosis of paranoid schizophrenia, while another resident's screening was not updated after their stay exceeded 30 days. Staff interviews revealed lapses in verifying and updating PASRR screenings.
A resident at moderate risk for falls was left unattended in a shower room, resulting in a fall, while another resident with cognitive impairment had unsecured bed rails, posing a safety hazard. Staff failed to provide necessary supervision and did not identify or report the loose bed rails, leading to deficiencies in maintaining a safe environment.
The facility failed to complete and submit the Discharge MDS for three residents within the required timeframes, resulting in non-compliance with CMS regulations. The MDS coordinator confirmed the oversight, acknowledging that the assessments were overdue and not submitted as required by federal guidelines.
A resident with multiple wounds did not receive consistent weekly wound assessments as required by the facility's policy. Despite having serious conditions like sepsis and diabetes, the resident's wounds on the toes, knee, mid spine, and perianal area were not assessed for several weeks. The DON confirmed these lapses, which could affect wound healing progress.
The facility was found to have unsafe flooring conditions, with multiple holes in the hallway and rehabilitation area. Maintenance staff acknowledged the unsafe condition, which contradicts the facility's policy requiring floors to be maintained in a clean, safe, and sanitary manner.
A resident with end-stage renal disease fell from a wheelchair due to improper positioning by a CNA, who failed to notify a nurse for assessment before transferring the resident back. The facility also did not document the incident correctly, violating its policies.
The facility failed to conduct a criminal background check for a re-hired CNA before they began working with residents, contrary to its policy. The CNA returned to work without the required check, which was completed over nine months later, potentially compromising resident safety.
A resident with peripheral vascular disease and osteoarthritis experienced recurrent skin tears during transfers due to inadequate investigation and documentation by the facility. Despite multiple incidents, the facility failed to determine the exact causes, leading to repeated injuries. The DON confirmed the lack of follow-up investigations, and the facility's policies requiring thorough investigations were not adhered to.
A resident with peripheral vascular disease and osteoarthritis frequently refused the RNA program, but the facility failed to notify her physician in a timely manner and did not update her care plan to address these refusals. Despite the refusals being reported to an LVN, there was no documentation of physician notification or a revised care plan, as confirmed by the DON.
A resident with cognitive impairment was found with another resident's hands inside her diaper due to inadequate monitoring of the latter's wandering behavior. Despite a history of entering other residents' rooms, there was no specific care plan or monitoring in place for the resident with wandering behavior, leading to a violation of the facility's abuse prevention policy.
Failure to Transcribe Wound Care Order to Treatment Record
Penalty
Summary
A resident with a diagnosis of chronic venous hypertension and bilateral lower extremity ulcers was admitted to the facility. The resident received a treatment order from the wound physician to cleanse a venous ulcer on the right lower lateral leg with normal saline, apply Xeroform, and cover with a dry dressing and Kerlix. However, review of the Treatment Administration Record (TAR) for the relevant month showed that this treatment order was not transcribed onto the TAR. During an interview, the treatment nurse confirmed that the wound care order was not present on the TAR, acknowledging that the wound might not receive the prescribed treatment if the order was not documented for licensed nurses to follow. The facility's policy requires that drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the resident's wound care order.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow infection control practices after assisting a resident who had a physician's order for ice therapy to the knee. The CNA entered the resident's room, donned gloves, and repositioned the ice wrap on the resident's knee as requested. After completing the task, the CNA removed her gloves and exited the resident's room into the hallway without performing hand hygiene. During an interview, the CNA acknowledged that she should have sanitized her hands upon leaving the room. The facility's infection control policy requires staff to use alcohol-based hand rub or soap and water after direct resident contact and after removing gloves, and specifies that glove use does not replace hand hygiene. The infection preventionist confirmed that staff are expected to sanitize their hands when leaving residents' rooms.
Failure to Communicate and Document Resident Code Status Results in Inappropriate CPR
Penalty
Summary
The facility failed to ensure proper communication and documentation of a resident's code status, resulting in confusion among staff regarding whether to perform resuscitation efforts. The case manager did not immediately communicate the change in the resident's code status from Full Code to Do Not Resuscitate (DNR) after receiving a new POLST form from the resident's daughter, which was signed by both the resident and her attending physician. Additionally, the previous POLST indicating Full Code was not promptly removed from the electronic medical record (EMR), and the change in code status was not immediately documented in the EMR after verification with the resident and her daughter. This lack of timely communication and documentation led to conflicting information in the resident's medical records. When the resident became unresponsive, staff and emergency medical services (EMS) encountered two different POLST forms: one indicating DNR and another indicating Full Code. The EMS team questioned the validity of the DNR POLST due to a missing back page and ultimately relied on the Full Code POLST found in the EMR, leading them to initiate CPR, which was inconsistent with the resident's confirmed wishes. Interviews with facility staff revealed that the case manager acknowledged the failure to remove the outdated POLST from the EMR and to document the confirmed DNR status in a timely manner. Nursing staff were unaware of the voided status of the Full Code POLST and could not provide clear guidance to EMS during the emergency. The director of nursing also confirmed that the updated POLST had not been uploaded to the EMR. The facility's own performance improvement project identified root causes including dual POLST forms, incomplete documentation, and lack of clear workflow for verifying POLST accuracy during emergencies.
Failure to Notify Physician and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident experienced a significant change in mental status. The resident, who was admitted following an orthopedic surgical amputation, was initially alert and oriented to person, place, and time. However, nursing progress notes documented a decline to being alert and oriented to person only. Instead of directly notifying the physician as required by facility policy and the hospital discharge instructions, the nurse left a message in the facility's communication binder regarding the change in condition. Additionally, the facility failed to transcribe and implement a wound care order from the resident's hospital discharge instructions. The discharge orders specified daily dressing changes for the surgical site, but this order was not entered into the SNF physician orders or the Treatment Administration Record. As a result, the wound dressing was not changed for two days. Both the wound care nurse and the DON confirmed that the wound care order was missing from the resident's SNF orders, and the wound care nurse was unaware of the need for dressing changes during that period.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident, specifically regarding the discharge status. The resident, who had a medical history including a humerus fracture, history of falling, and muscle weakness, was admitted to the facility and later discharged home with a family member and a referral to a home health agency. However, the discharge-return not anticipated MDS inaccurately indicated that the resident was discharged to a short-term general hospital. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the error in coding. The MDS Coordinator acknowledged the incorrect coding, stating that the resident was discharged home, not to a hospital. Both the DON and the Administrator expressed their expectation for accurate MDS coding, highlighting the discrepancy between the documented discharge plan and the MDS coding.
Deficiencies in PASRR Screening for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and timely submission of Level I Preadmission Screening and Resident Reviews (PASRRs) for two residents. Resident #41 was admitted with a diagnosis of paranoid schizophrenia, which was not reflected in the Level I PASRR screening completed by the hospital prior to admission. The screening inaccurately indicated that the resident did not have a serious mental disorder and was not prescribed psychotropic medication, leading to the conclusion that a Level II evaluation was not required. Both the MDS Coordinator and the Director of Nursing acknowledged the oversight in not verifying the accuracy of the hospital-completed screening. For Resident #70, the facility did not submit a Level I PASRR screening after the resident remained in the facility longer than 30 days, despite the initial screening indicating a serious mental disorder and the use of psychotropic medications. The resident was initially considered exempt from the PASRR process due to an expected stay of less than 30 days following a hospital discharge. However, the MDS Coordinator admitted that the facility failed to review and update the PASRR screening when the resident's stay extended beyond the 30-day exemption period. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of adherence to the PASRR process and a failure to ensure the accuracy and completeness of the screenings. The Administrator was not involved in the PASRR process but expected compliance with the guidelines. These deficiencies highlight lapses in the facility's procedures for managing PASRR requirements, particularly in verifying and updating screenings as necessary.
Inadequate Supervision and Hazardous Environment in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who was at moderate risk for falling. The resident, who had a medical history of muscle weakness, difficulty in walking, spinal stenosis, and muscle spasms, required partial/moderate assistance with bathing and supervision during transfers. Despite this, a CNA left the resident alone in the shower room to obtain linens, resulting in the resident sliding out of the shower chair and falling to the floor. The CNA acknowledged awareness of the need for supervision but left the resident unattended due to the inconvenience of wet towels. In another incident, the facility failed to ensure the environment was free of accident hazards for a resident with a history of falls and cognitive impairment. The resident, who was totally dependent on staff for bed mobility and transfers, had bed rails that were not secure. Observations revealed a loose bed rail with a gap between the bed and the rail, which could pose a risk of falling. Staff members, including CNAs and LVNs, were unaware of the loose bed rail, and the issue was not reported to maintenance. The facility's policy required periodic checks for bed rail safety, but there was no documentation of these checks. The Director of Nursing and the Administrator both stated that staff should identify and report hazards, such as loose bed rails, to ensure resident safety. However, the loose bed rail was not brought to their attention, and the facility did not have a documented process for checking the bed rails regularly. The lack of supervision and failure to maintain a hazard-free environment contributed to the deficiencies identified in the report.
Failure to Timely Submit Discharge MDS for Residents
Penalty
Summary
The facility failed to complete and submit the Discharge Minimum Data Set (MDS) for three residents within the required timeframes, resulting in non-compliance with CMS regulatory requirements. Resident 1 was discharged on 9/14/24, Resident 2 on 9/13/24, and Resident 3 on 9/17/24. As of 11/6/24, the discharge MDS for all three residents were overdue, still in progress, and not submitted to CMS. This was confirmed during an interview with the MDS coordinator, who acknowledged that the discharge MDS should have been completed within 14 days and submitted within 28 days post-discharge. The facility's policy, dated 7/2017, assigns the responsibility of ensuring timely submission of resident assessments to the assessment coordinator or designee, in accordance with federal and state guidelines. The CMS's Resident Assessment Instrument (RAI) Manual specifies that the discharge MDS Completion Date should be no later than 14 days after discharge, and the Transmission Date should be no later than 14 days after the Completion Date. The failure to adhere to these guidelines led to the deficiency noted in the report.
Inconsistent Wound Assessments for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services as required, specifically in the consistent completion of weekly wound assessments. The resident, who was admitted with serious conditions including sepsis, atelectasis, and diabetes, had multiple wounds on various parts of the body, including the toes, knee, mid spine, and perianal area. Despite the requirement for weekly assessments, the wounds on the resident's toes, knee, and mid spine were not assessed for several weeks at different intervals, and the perianal wound was not assessed until several months after the order was given. The Director of Nursing confirmed the lapses in the wound assessments during an interview, acknowledging that the assessments were not conducted as required by the facility's policy. The facility's policy mandates a comprehensive skin assessment with every risk assessment, and documentation of findings on a facility-approved skin assessment tool. The failure to conduct these assessments resulted in an undetermined wound status, which could potentially affect the progress of wound healing for the resident.
Unsafe Flooring Conditions in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents and staff due to the presence of multiple holes in the flooring. During an observation, it was noted that the hallway in front of nursing station 3 had a hole measuring 6 x 3 x 0.5 inches below the handrail. Additionally, the rehabilitation area contained eight holes, each measuring 5 3/4 x 3/4 x 0.5 inches. During a concurrent interview, maintenance staff acknowledged that the condition of the floor was not good and not safe. The facility's policy from December 2009 requires that floors be maintained in a clean, safe, and sanitary manner.
Failure to Ensure Resident Safety and Proper Documentation
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 1, who was at risk due to improper positioning in a wheelchair by a Certified Nursing Assistant (CNA A). The resident, who had end-stage renal disease and was dependent on staff for transfers, was not positioned correctly in the wheelchair, with her buttocks only halfway in. This improper positioning led to the resident sliding off the wheelchair and falling to the bathroom floor. Despite the fall, CNA A did not immediately notify a Licensed Nurse (LN) to assess the resident for possible injuries before transferring her back to the wheelchair and then to bed. Interviews with various staff members, including Licensed Vocational Nurses (LVN B and LVN D), other CNAs, and the Director of Staff Development (DSD), confirmed that the standard procedure was not followed. The staff emphasized the importance of ensuring that a resident's buttocks are fully positioned in the wheelchair to prevent falls and the necessity of notifying a Charge Nurse immediately after any fall, whether witnessed or unwitnessed, for an assessment of possible injuries. The CNA A admitted to not following these procedures, which are outlined in the facility's policies and procedures. Additionally, the facility failed to document the correct information regarding the fall incident in Resident 1's medical records. Despite interviews conducted by the Director of Nursing (DON) and the DSD with CNA A, the accurate details of the incident were not recorded. The facility's policies require thorough documentation of fall incidents, including the cause and details of how the fall occurred, but this was not adhered to in this case.
Failure to Conduct Timely Background Check for Re-hired CNA
Penalty
Summary
The facility failed to implement its policy and procedure related to staff screening procedures for hiring direct access employees. Specifically, the facility did not conduct a criminal background check for a Certified Nursing Assistant (CNA A) prior to re-employment. CNA A had gone on vacation and did not return for over 90 days. Upon re-hiring CNA A, the facility allowed them to start working with residents the day after re-employment without completing the required criminal background check. This oversight was confirmed during an interview and record review with the Director of Staff Development (DSD), who admitted to forgetting to complete the background check before rehiring CNA A. The facility's policy, revised in March 2019, mandates that background checks, including criminal conviction investigations, be conducted on all applicants for positions with direct access to residents. These checks are to be initiated within two days of an employment offer and completed before employment begins. However, in this case, the criminal background check for CNA A was not completed until more than nine months after they were re-hired. This lapse in following the established procedure had the potential to compromise resident safety.
Failure to Investigate Recurrent Skin Tear Incidents
Penalty
Summary
The facility failed to ensure the safety of a resident by not thoroughly investigating the root causes of recurrent skin tear incidents during transfers from bed to wheelchair and after using the bathroom. The resident, who had peripheral vascular disease, osteoarthritis, muscle weakness, and moderately impaired cognition, experienced four skin tear incidents on her lower legs over several months. Despite these incidents, there was no comprehensive investigation or documentation to determine the exact causes of the skin tears. The resident's medical records and care plans indicated that she required partial/moderate assistance during transfers and had no impairment in her extremities. However, interviews with staff revealed that the resident's legs were repeatedly caught in the wheelchair during transfers, leading to skin tears. The facility's Director of Nursing confirmed the lack of documentation and follow-up investigations for these incidents, acknowledging that they should have been investigated and documented. The facility's policies and procedures required complete investigations of resident injuries and documentation of findings, but these were not followed in the case of the resident's skin tears. The interdisciplinary team records also lacked detailed discussions of the incidents, and care plan interventions did not adequately address the underlying causes of the skin tears. This lack of thorough investigation and documentation contributed to the recurrence of the incidents.
Failure to Notify Physician and Update Care Plan for RNA Program Refusals
Penalty
Summary
The facility failed to provide adequate care and services for a resident by not notifying the resident's physician about her repeated refusals to participate in the Restorative Nursing Assistant (RNA) program in a timely manner. The resident, who was admitted with diagnoses including peripheral vascular disease, osteoarthritis, muscle weakness, and gait abnormalities, frequently refused the RNA ambulation and omni cycle programs. Despite these refusals being reported to a Licensed Vocational Nurse (LVN), there was no documentation of physician notification during May 2024, as confirmed by the LVN and the Director of Nursing (DON). Additionally, the facility did not update the resident's care plan to address her frequent refusals of the RNA program. The resident's care plan initially included participation in the RNA program to maintain gait function and strength, but her refusals were not incorporated into a revised nursing care plan. The DON acknowledged that the licensed nurses should have notified the physician within seven days of the refusals and initiated a nursing care plan to address the issue, as per the facility's policies and procedures.
Failure to Prevent Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from unwanted touching, resulting in a deficiency related to abuse prevention. A receptionist discovered a resident with cognitive decline and wandering behavior inside another resident's room, with his hands inside her diaper. The resident who was touched had severe cognitive impairment due to late-onset Alzheimer's disease and was unable to respond verbally or make eye contact during observations. The incident occurred because the facility did not have adequate monitoring in place for the resident with wandering behavior, despite his history of entering other residents' rooms and taking their belongings. The facility's staff, including a licensed vocational nurse and a certified nursing assistant, confirmed the incident and noted that the resident who wandered had previously been known to enter other residents' rooms. However, there was no specific care plan addressing his wandering behavior, and monitoring of his whereabouts was not implemented until after the incident. The facility's policy on abuse prevention was not effectively followed, as the resident's right to be free from abuse was compromised. Interviews with staff and a review of the facility's policy highlighted the lack of a specific plan to monitor the resident's wandering behavior. The facility's failure to implement appropriate monitoring measures and address the resident's behavior led to the incident, which was a violation of the resident's rights and the facility's abuse prevention policy.
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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.
Illustrative
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Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| A Grace Sub Acute & Skilled Care | 0.6 mi | ★★★★★ | 3 | 0 |
| Baywood Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Courtyard Care Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Empress Care Center, Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| White Blossom Care Center | 1.8 mi | ★★★★★ | 22 | 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 July 2026) and official state health department websites.