Creekside Healthcare Center

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 1), the facility failed to provide Resident 1's Responsible Party (RP) copies of requested medical records within the required timeframe when she requested Resident 1's medical records by mail on [DATE] and sent the same request with documents via fax on [DATE]. The requested medical records were not released until [DATE] after the RP got a lawyer to make the same request on her behalf. This failure resulted in a delay in obtaining Resident 1's medical records, causing RP undue concern pertaining to obtaining the requested medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Resident 3, Resident 18, and Resident 45) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II PASRR evaluation and determination.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). This failure had the potential to prevent residents from receiving appropriate required mental health services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were observed by one of one sampled laundry staff (LS) when the LS was not wearing a gown while moving soiled linen from the soiled linen hamper in to the washer. This failure had the potential for cross contamination and spread of infections among 72 residents at the facility. During a concurrent observation and interview on 8/7/25 at 10:09 a.m. with the LS and Certified Nursing Assistant (CNA) 1 in the laundry room, the LS was observed grasping soiled linen from the hamper in to the washer only with gloved hands. The LS stated she had never used a gown or was told to use a gown when putting the dirty linen in to the machine. The LS stated wearing the gown could protect staff and other residents from the spread of infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine medications to meet the needs of one of two sampled residents (Resident 62) and ensured controlled medications (those with high potential for abuse and addiction) were accurately reconciled for two of three sampled residents (Resident 3 and 39) when:1. Resident 62's basaglar insulin (medication used to help manage blood sugar levels) and epogen (medication used to treat anemia, a condition where the blood doesn't carry enough oxygen to the rest of the body) were not available for administration. These failures resulted in Resident 62 to not receive medications as ordered by the physician.2. Resident 3 and 39's controlled drug records were documented illegibly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for flies and gnats in three of three units designated for resident care. A dead kitten was found outside Resident 24's window for more than 22 hours. The failure to effectively treat flies and gnats and leaving the dead kitten outside Resident 24's room resulted in Resident 24 feeling ugly and grossed out and had the potential to result in infection for all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 %. During the medication pass, three medication errors were observed out of 32 opportunities for three of six residents, resulting in an error rate of 9.38%. 1. Amlodipine (medication for management of high blood pressure) for Resident 1 was unavailable and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure. 2. Semglee pen U-100 insulin (Insulin Glargine, a long acting insulin) subcutaneous injection was administered to Resident 45 without following manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications and biologicals (a class of medications which are grown and then purified from large-scale cell cultures of bacteria or yeast, or plant or animal cells) in a safe condition when the temperature in one of two medication refrigerators was out of range in accordance with Federal, State, and CDC storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the resident. During a concurrent interview and observation of medication refrigerator 2 (med fridge 2) on 5/21/24 at 11:55 a.m. with RN2, in medication storage room [ROOM NUMBER], the thermometer inside med fridge 2 indicated 32 degrees (°) Fahrenheit (F). [...]

Inspectors wroteBased on interview and record review, for three of three sampled residents (Resident 49, Resident 65 and Resident 68) reviewed for arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute [disagreement or claim among parties where one party claims to have been harmed] after receiving evidence and hearing arguments) agreement, the facility failed to ensure the arbitration agreement was explained in a manner they understood. This failure had the potential to result in violation of the residents' right to make informed decisions and choices about important aspects of healthcare and welfare.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess one of four sampled residents (Resident 322) for right forearm swelling. This failure resulted in Resident 322 experiencing pain and limited range of motion of the right arm, and placed Resident 322 at risk of untreated edema, further pain skin damage, and fluid overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment and a safe transfer to prevent accident for one of eight sampled (Resident 2) when Resident 2 fell from the Hoyer lift during transfer from bed to chair by a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN). This deficient practice resulted in Resident 2 sustaining a superficial scalp laceration and hematoma due to the witnessed fall from the Hoyer lift.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pharmaceutical services when Resident 1's medication, amlodipine (medication used to treat high blood pressure) was not available and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure for Resident 1 During a review of Resident 1's admission Record, undated, the admission Record indicated Resident 1 was admitted in December 2019 with diagnoses that included hypertension, chronic kidney disease, and dementia. During a concurrent medication pass observation and interview on 5/22/24 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 checked Resident 1's blood pressure and stated Resident's BP was 125/58. LVN stated order indicated to hold if Systolic BP is less than 100. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received quetiapine (an antipsychotic medication, a class of medication that affects brain activities associated with mental processes and behavior) without an appropriate indication for use or appropriate behavior monitoring. This failure resulted in Resident 68's behavior not being appropriately monitored for the use of quetiapine and placed Resident 68 at risk of experiencing untreated psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to report the fall incident of Resident 2 to the California Department of Public Health (CDPH) and other appropriate agencies, as required by the federal or state regulations. This failure had the potential in delay of investigation and affects the health, safety, or welfare of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after an identified concern for one of three sample selected residents (Resident 1) when Resident 1 informed the staff of the facility about his sensitivity to the scents. The facility did not make a care plan and follow up with Resident 1's concern. This failure resulted in frustration for Resident 1 and having to inform each of the staff himself about his issue with scents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage when the eye drops and ear drops were stored next to each other in green and white boxes and there was an expired 1000 ml (milliliter) bag of 10% Dextrose (sugar water solution given intravenously or into the vein) in the medication storage room. These failures had the potential for medication errors to occur (for example, administering ear medication into the eye which could cause blindness) or or the resident to receive expired intravenous (IV) fluids.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow a current seasonal menu and meal plan when the facility used the Fall/Winter 2021 menu to prepare the residents' meals. This deficient practice did not ensure seasonal foods which offer variety, palatability, and nutritional value were made available to residents.

Inspectors wroteBased on observation and interview, the facility failed to serve palatable food when the facility served chicken rice soup that was too salty. This deficient practice had the potential to cause residents to not enjoy their meal and decline to eat.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow proper sanitation and food storage practices as follows: a. Dishwashing racks with brownish discoloration, b. Plate covers had a faded, discolored appearance c. Air vent had a thick layer of black dust. These deficient practices had the potential to result in foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (Resident 274) of two sampled residents (Resident 47 and 274) was free from physical abuse when; Resident 47 grabbed Resident 274 on the back of the neck during an altercation in the lobby area. This deficient practice resulted in repeated episodes of resident to resident altercation and had the potential to cause emotional distress, pain, and injury.

Inspectors wroteBased on interviews and record review, the facility failed to revised one of two sampled residents (Resident 47) care plans with new interventions to address Resident 47's aggressive arguments and complaint. This deficient practice did not ensure interventions were developed and implemented to avoid repeat altercations.

Inspectors wroteBased on interviews, record review, for one (Resident 27) of five random sampled resident charts reviewed for their pneumonia vaccination, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP-group of medical a public health experts) based on the age group and had no medical contraindication against it. This failure increased the risk and potential for Resident 27 to acquire, transmit or experience complications from pneumococcal disease.