Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Post Acute during CMS and state inspections, most recent first.
A resident with idiopathic pulmonary fibrosis and chronic respiratory failure had multiple scheduled evening medications, including antihypertensives, lipid-lowering agents, an antiplatelet, gabapentin, a supplement, and pirfenidone. On one evening, the MAR for this resident showed no nursing signatures or documentation for any of the 8:00 PM to 10:00 PM doses. The DON confirmed the absence of documentation, and an LVN later stated he had administered the medications but forgot to record them, despite facility policy requiring immediate documentation of medication administration in the MAR/EMAR.
A resident with IPF and chronic respiratory failure had a physician’s order for Pirfenidone 801 mg by mouth every 8 hours, but three scheduled doses were not administered. Review of the MAR showed the missed doses, and two LVNs reported they did not give the medication because they could not locate it in the medication cart, with one LVN also not confirming availability with the prior nurse. The DON reported that expected nurse-to-nurse communication at shift change did not occur, and the facility’s own medication administration policy requiring adherence to physician orders was not followed.
Staff without appropriate qualifications completed and signed quarterly nutrition assessments for multiple residents, with no verification by a Registered Dietitian or other qualified personnel. This resulted in inaccurate documentation, including incorrect weight ranges, and affected the nutritional evaluation process for a large group of vulnerable residents.
Multiple food items in a resident refrigerator were found unlabeled and undated, and refrigerator temperatures were not monitored or recorded for two months. A Social Worker confirmed that facility policy requiring labeling, dating, and temperature monitoring was not followed, potentially affecting 25 medically compromised residents.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Surveyors found that medications, including a blood thinner and wound ointment, were not properly labeled with expiration dates or resident identification, and that medication carts were left unlocked and unattended by nursing staff, contrary to facility policy.
Staff did not document discussions or offers of assistance regarding advance directives for two residents, one with acute respiratory failure and tracheostomy status and another with traumatic brain injury and chronic respiratory failure. Required sections in the medical records and POLST forms were left blank, and facility policy on advance directive documentation was not followed.
A resident with a documented diagnosis of schizophrenia did not have this condition accurately coded on their quarterly MDS assessment, despite ongoing psychiatric evaluation and clear documentation in medical records. The MDS nurse and IDON confirmed the omission and acknowledged that facility policy requiring accurate assessments was not followed.
A resident admitted with multiple diagnoses, including schizophrenia, did not have their PASARR updated or re-submitted after a new psychiatric diagnosis was documented. The MDS nurse acknowledged responsibility for updating the PASARR but did not complete this task, contrary to facility policy requiring all admissions to have appropriate PASARR documentation.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not implement adequate measures to prevent new ulcers from developing.
A resident with significant physical impairments and high fall risk fell from bed while being repositioned by a CNA, who rolled the resident away from herself and did not notice the resident was too close to the bed's edge. The incident resulted in uncontrolled pain and required hospital treatment. The facility lacked a policy on bed mobility or turning residents during care.
A resident with a tracheostomy and ventilator dependence did not have an AMBU bag at the bedside as required by facility policy. Staff confirmed the absence of the device, which was supposed to be immediately available for manual ventilation in emergencies, and were unable to locate it in the resident's room.
A resident with complex respiratory needs had conflicting code status orders (DNR and Full Code) documented in the EHR. The Interim DON confirmed the EHR was incorrect and should have only indicated DNR, and stated that licensed nurses are responsible for ensuring code status accuracy.
A CNA entered a Contact Precaution room of a resident with chronic respiratory failure and Candida Auris without donning the required PPE, specifically a gown and gloves, as mandated by facility policy. The CNA performed care tasks after only donning gloves inside the room, and staff interviews confirmed this was not in accordance with infection control procedures.
A facility failed to ensure proper management of G-tubes for three residents, as an LVN did not verify tube placement before administering medications. This oversight, involving residents with complex medical conditions, was against the facility's policy and increased the risk of aspiration.
A facility failed to ensure medications were explained to three residents before administration. An LVN administered medications without explanation to residents with various medical conditions, including acute respiratory failure and cerebral infarction. The DON confirmed that the facility's policies requiring explanation of medications and resident rights were not followed.
The facility failed to secure the medication refrigerator in the medication room, as it was found unlocked during a survey. The IP acknowledged the issue, and the DON confirmed that the facility's policy requires the refrigerator to be locked at all times. The policy also mandates that controlled medications be stored separately under double lock. This deficiency posed a risk of unauthorized access and potential harm to 49 residents.
A facility failed to document the Restorative Nursing Weekly Summary for a resident with limited range of motion. The resident had diagnoses including anoxic brain damage and muscle contractures, with orders for a Restorative Nursing Assistant program to maintain range of motion. However, documentation was missing for several weeks, as confirmed by staff and the Director of Nursing, who noted that the facility's policy on range of motion exercises was not followed.
Failure to Document Evening Medication Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to follow its medication administration and documentation policies for one resident on a specific evening medication pass. The resident, admitted with idiopathic pulmonary fibrosis and chronic respiratory failure with hypoxia, had multiple scheduled medications between 8:00 PM and 10:00 PM on December 31, 2025, including antihypertensives (losartan, amlodipine, carvedilol), lipid-lowering agents (atorvastatin, ezetimibe), a nutritional supplement (Pro-Stat), an antiplatelet (ticagrelor), a neuropathic pain medication (gabapentin), and pirfenidone for respiratory failure. Review of the December 2025 MAR showed that for this date, there were no nursing signatures or documentation indicating that any of these scheduled evening medications were administered. During a concurrent telephone interview and record review, the DON confirmed that the MAR lacked documentation that the resident received the scheduled 8:00 PM to 10:00 PM medications on that date. In a separate telephone interview, the LVN assigned to administer these medications stated that he did give all of the resident’s scheduled evening medications but forgot to document them on the MAR. He acknowledged that he should have signed the MAR immediately after administering the medications rather than waiting until the end of his shift. Facility policies titled “Specific Medication Administration Procedure” and “Medication Administration” required the licensed nurse to document medication administration in the MAR/EMAR after giving the medications, which was not done in this instance.
Failure to Administer Ordered Pirfenidone Doses as Prescribed
Penalty
Summary
Surveyors identified a deficiency in medication administration when a resident with idiopathic pulmonary fibrosis (IPF) and chronic respiratory failure with hypoxia did not receive the prescribed medication Pirfenidone on three documented occasions. The resident had a physician’s order, dated December 21, 2025, for Pirfenidone 801 mg by mouth every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM. Review of the December 2025 Medication Administration Record (MAR) showed missed doses on December 26 at 2:00 PM, December 27 at 2:00 PM, and December 28 at 10:00 PM. The facility’s policy and procedure for Medication Administration required that medications be administered in accordance with written physician orders. During interviews, LVN 1 acknowledged that he did not administer the resident’s Pirfenidone on December 26 and 27 at 2:00 PM because he could not find the medication in the cart and did not check with the previous nurse to determine if the medication was available. LVN 2 stated she did not administer the Pirfenidone dose on December 28 at 10:00 PM because she was unable to locate the medication in the cart. The DON stated that her expectation was that communication between nurses should occur during shift changes and acknowledged that this communication did not occur, resulting in the resident not receiving the medication as prescribed. The facility failed to ensure that Pirfenidone was administered according to the physician’s orders and its own medication administration policy.
Unqualified Staff Conducted Nutrition Assessments Without Proper Oversight
Penalty
Summary
The facility failed to ensure that staff with the appropriate competencies and skill sets completed residents' Quarterly Nutrition Assessments. Specifically, the Dietary Service Supervisors (DSS 1 and DSS 2), who were not qualified to perform such assessments, completed and signed off on these evaluations for multiple residents over several months. Record reviews confirmed that these assessments were not verified by any other qualified personnel, such as a Registered Dietitian (RD). During interviews, both the RD and the Interim Director of Nursing (IDON) confirmed that the DSS did not have the scope of practice or qualifications to conduct these assessments, and that the process lacked oversight from appropriately credentialed staff. One resident's assessment included an incorrect Ideal Body Weight Range (IBWR), which the RD could not verify and stated was not accurate. The lack of qualified staff conducting and verifying these nutrition assessments affected a group of 52 highly vulnerable residents, as the assessments are intended to identify nutritional deficiencies or risks and guide personalized interventions. The deficiency was identified through interviews and record reviews, which revealed that the assessments were being completed solely by unqualified staff without proper verification.
Failure to Safely Store and Monitor Resident Food
Penalty
Summary
The facility failed to store resident food safely by not labeling or dating multiple food items in the resident refrigerator and by not monitoring or recording the refrigerator's temperature for the months of June and July 2025. During an observation in the dining room, it was found that food items in the resident refrigerator were not labeled with names or dates, and two thermometers were located outside the fridge. The Social Worker confirmed that food items should be labeled and dated according to facility policy. Additionally, a review of temperature logs revealed that no temperatures had been recorded for the resident refrigerator during the specified months. The facility's policy required all refrigeration units to have internal thermometers and for perishable foods to be stored in resealable containers labeled with the resident's name, the item, and the use-by date, which was not followed. These failures had the potential to affect 25 medically compromised residents who were able to store food in this refrigerator.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Labeling and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications and biologicals. Two bubble packs containing Eliquis, a blood thinner prescribed to a resident, were found in a medication cart without expiration dates. The nurse confirmed that expiration dates are typically verified upon receipt from the pharmacy, but these packs were missing the required information. Additionally, eight tubes of Santyl ointment, used for wound care, were discovered in a treatment cart without resident identification labels. The facility's policy and procedure require all prescription drugs to be properly labeled with specific information, including the resident's name and expiration date, but these requirements were not met. Further observations revealed that two medication carts were left unlocked and unattended by nursing staff for extended periods during medication administration. One cart was left unattended for ten minutes, and another for five minutes, both times without being secured as required by facility policy. Staff acknowledged that the carts should have been locked when not in use, and the facility's policy mandates that medication carts must be securely locked at all times when out of the nurse's view. These lapses in medication security and labeling were verified through interviews and policy review.
Failure to Document and Discuss Advance Directives with Residents
Penalty
Summary
The facility failed to provide evidence that staff discussed advance directives with two residents, as required by policy. For one resident with diagnoses including acute respiratory failure with hypoxia, cirrhosis of the liver, major depressive disorder, and tracheostomy status, there was no documentation in the electronic health record regarding whether the resident had an existing advance directive or had been informed of the right to formulate one. Additionally, the section of the resident's Physician’s Order for Life Sustaining Treatment (POLST) form regarding advance directives was left blank. The Corporate Medical Records Resource confirmed the absence of documentation and acknowledged the incomplete POLST form. For another resident admitted with traumatic hemorrhage of the cerebrum and chronic respiratory failure with hypoxia, the clinical record also lacked documentation that the resident or their representative was offered assistance to accept or decline the establishment of an advance directive. The Interim Director of Nursing reviewed the record and confirmed that the facility’s policy, which requires staff to offer assistance and document the resident’s decision regarding advance directives, was not followed in this case.
Failure to Accurately Code Schizophrenia Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately completed for a resident with a diagnosis of schizophrenia. The resident, who was admitted with multiple diagnoses including schizophrenia, had this condition documented in their admission record and in several psychiatrist assessments. However, the quarterly MDS assessment did not reflect the active diagnosis of schizophrenia, despite ongoing evaluation and monitoring for the condition by psychiatric staff. During interviews and record reviews, the MDS nurse acknowledged that the resident's schizophrenia should have been coded as an active diagnosis on the MDS assessment. The Interim Director of Nursing confirmed that the facility's policy requires assessments to accurately reflect the resident's status and stated that this policy was not followed in this instance. The omission resulted in the resident's MDS assessment not accurately representing their care and support needs.
Failure to Update PASARR Following New Diagnosis
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) was updated and re-submitted for a resident who was admitted with multiple diagnoses, including schizophrenia, respiratory failure, and hypothyroidism. Upon review, it was found that eight days after admission, a psychiatrist's assessment documented a diagnosis of schizophrenia for the resident. However, there was no evidence in the clinical record that the PASARR was updated or re-submitted to reflect this new diagnosis. During an interview and record review, the Minimum Data Set Nurse confirmed that it was her responsibility to update and re-submit the PASARR when new diagnoses were identified, but acknowledged that she did not do so in this case. The facility's policy requires that all admissions have the appropriate PASARR completed and that the administrator is accountable for monitoring this process, but this procedure was not followed for the resident in question.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not take adequate measures to prevent the development of new ulcers. This deficiency indicates that necessary interventions to manage existing pressure ulcers and prevent further skin breakdown were not implemented or maintained as required.
Resident Fall Due to Improper Bed Mobility During Care
Penalty
Summary
A resident with a history of osteomyelitis of the vertebra, ventilator dependence, and significant impairment in both upper and lower extremities on one side was identified as high risk for falls and disoriented to person, place, time, and situation at all times. While receiving care from a CNA, the resident was being repositioned in bed for a brief change. The CNA rolled the resident away from herself, contrary to expected practice, and did not notice that the resident was too close to the edge of the bed. As a result, the resident rolled off the bed, landing on her knees and coccyx, which led to uncontrolled pain and required hospital evaluation and treatment. Facility records and interviews confirmed that only one CNA was present during the incident, and the facility did not have a policy or procedure regarding bed mobility or turning residents while in bed. The root cause analysis by the interdisciplinary team identified that the CNA miscalculated the resident's roll during care, leading to the fall. The facility's policy on safety and supervision emphasized making the environment as free from accident hazards as possible, but this was not achieved in this instance.
Failure to Provide Required AMBU Bag at Bedside for Ventilator-Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and ventilator dependence, who had a history of acute respiratory failure with hypoxia, did not have an Artificial Manual Breathing Unit (AMBU) bag at the bedside as required by facility policy. During an observation, it was noted that the AMBU bag was not present in the resident's immediate vicinity. Multiple staff interviews confirmed that an AMBU bag was supposed to be at the head of the bed for all residents with a tracheostomy and ventilator, and that its absence was unacceptable. Staff searched the room but were unable to locate the required equipment. The facility's policy, dated April 17, 2025, specified that a manual resuscitator device must be placed at the bedside of each resident. Both the respiratory therapist and the respiratory therapy resource confirmed the importance of having the AMBU bag readily available for manual ventilation in case of emergency. The deficiency was identified through observation, staff interviews, and review of the facility's policy and the resident's medical record.
Inaccurate Code Status Documentation in EHR
Penalty
Summary
The facility failed to ensure that the documentation in the Electronic Health Record (EHR) was accurate for a resident reviewed for advance directives. Specifically, the resident's code status in the EHR was documented as both Do Not Resuscitate (DNR) and Full Code, which are contradictory orders regarding life-sustaining measures. This discrepancy was identified during a review of the resident's EHR, which should have accurately reflected the resident's wishes as indicated in the Physicians Orders for Life Sustaining Treatment (POLST) and other medical records. The resident involved had a medical history that included acute respiratory failure with hypoxia, tracheostomy status, and dependence on a mechanical ventilator. During interviews, the Interim Director of Nursing (IDON) confirmed that the EHR was incorrect and should have only indicated DNR status. The IDON also stated that it was the responsibility of licensed nurses to ensure the accuracy of code status documentation in the EHR. Facility policy requires that clinical records be complete and accurately documented, but this standard was not met in this instance.
Failure to Follow Contact Precaution Protocols for Infection Control
Penalty
Summary
A Certified Nurse Assistant (CNA) entered a room designated for Contact Precautions without donning the required personal protective equipment (PPE), specifically a gown and gloves, as mandated by the facility's infection control policies. The CNA performed hand hygiene, removed a lunch tray from the food cart, and entered the room, which had a visible Contact Precautions sign, without wearing PPE. Once inside, the CNA donned gloves but did not wear an isolation gown, then proceeded to reposition the resident, place a clothing protector, and open beverages, all while wearing the same pair of gloves and no gown. Upon exiting, the CNA acknowledged that she typically wears a gown and gloves before entering such rooms but could not explain the lapse on this occasion. The resident involved had been admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, and had been placed on Contact Precautions due to a diagnosis of Candida Auris. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Practitioner, confirmed that the facility's policy requires staff to perform hand hygiene and don both gown and gloves before entering any Contact Precaution room. Review of the facility's policies and procedures further supported these requirements, and the Operational Manager acknowledged that the CNA did not follow established protocols.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and management of gastrostomy tubes (G-tubes) for three residents, as observed during a survey. A Licensed Vocational Nurse (LVN) did not verify the placement of the G-tubes before administering medications to Residents 18, 19, and 6. This verification process involves listening for a gurgling sound when flushing air through the G-tube to confirm its correct position, as per the facility's policy. The failure to check the G-tube placement could potentially increase the risk of aspiration for these residents. Resident 18, who was admitted with acute respiratory failure, seizures, and chronic obstructive pulmonary disease, did not have their G-tube placement checked before medication administration. Similarly, Resident 19, with diagnoses including sepsis and cerebral infarction, and Resident 6, with anoxic brain damage and cerebral infarction, also did not have their G-tube placement verified. The Director of Nursing confirmed that the facility's policy, which requires checking tube placement every shift, was not followed by the LVN.
Failure to Explain Medications to Residents
Penalty
Summary
The facility failed to ensure that medications were explained to residents prior to administration, affecting three of the eight residents reviewed for medication administration. Specifically, the Licensed Vocational Nurse (LVN) did not inform Residents 18, 19, and 6 about the medications they were receiving during observations conducted on June 4, 2024. Resident 18, who was admitted with acute respiratory failure, seizures, and chronic obstructive pulmonary disease, was administered medications without explanation while lying in bed listening to the radio. Similarly, Resident 19, with diagnoses including sepsis and cerebral infarction, and Resident 6, with anoxic brain damage and cerebral infarction, were also given medications without being informed about them. During interviews, the LVN acknowledged the oversight, stating that explaining medications is part of the rights of medication administration. The Director of Nursing (DON) confirmed that the facility's policy and procedure, which requires explaining procedures to residents, was not followed. The facility's policy on Resident Rights also mandates that residents be informed of their medical condition and treatment, which was not adhered to in these instances. The DON expressed that the expectation was for all nurses to explain medications to their residents, indicating a lapse in following established protocols.
Medication Storage Security Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of medications in the medication room, as observed during a survey. Specifically, the medication refrigerator was found unlocked, which was acknowledged by the Infection Preventionist (IP) during an inspection. The Director of Nursing (DON) also confirmed that the facility's policy and procedure for medication storage requires that the medication refrigerator be locked at all times. The facility's policy further specifies that Schedule II, III, and IV controlled medications, including those requiring refrigeration, must be stored separately in a locked drawer or compartment under double lock. This deficiency was identified as having the potential to increase the risk of unauthorized access, misuse, and/or harm to the facility's 49 residents.
Failure to Document Restorative Nursing Weekly Summary
Penalty
Summary
The facility failed to document the Restorative Nursing Weekly Summary for a resident with limited range of motion, which was identified during an observation, interview, and record review. The resident, who was admitted with diagnoses including anoxic brain damage, cerebral infarction, and muscle contractures, was observed with a plush carrot toy in the right hand and a splint on the left hand. The resident's medical records indicated orders for a Restorative Nursing Assistant (RNA) program to maintain range of motion through various interventions, such as passive range of motion exercises and the application of orthotics and splints. However, during a review of the resident's records, it was found that there was no documentation of the RNA Weekly Summaries from April 26, 2024, to June 6, 2024. Both the Restorative Nursing Assistant and the Restorative Nursing Assistant Lead confirmed the absence of documentation for this period. The Director of Nursing also reviewed the facility's policy and procedure on range of motion exercises, which required documentation of the resident's participation, any problems or complaints, and the signature of the person recording the data. The policy was not followed, leading to the deficiency.
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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 Yucaipa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yucaipa Hills Post Acute | 0.2 mi | ★★★★★ | 9 | 0 |
| Cedar Mountain Post Acute | 1.9 mi | ★★★★★ | 17 | 0 |
| Oak Glen Post Acute | 4.9 mi | ★★★★★ | 0 | 0 |
| University Post Acute | 5.6 mi | ★★★★★ | 9 | 0 |
| Highland Springs Care Center | 5.9 mi | ★★★★★ | 23 | 0 |
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