Inspection visit
Inspection
26 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 26 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0557
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to be treated with respect and dignity and to retain and use personal
possessions.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to respect the rights and dignity of one resident
(Resident 15) reviewed for urinary catheter, when Resident 15's urinary catheter bag (a hollow, flexible tube
that collects urine from the bladder and leads to a drainage bag) was not covered with a dignity bag and
was visible to public view.
This failure had the potential to compromise Resident 15's dignity and violate his right to privacy.
Findings:
During an observation in Resident 15's room, on March 15, 2022, at 9:05 AM, Resident 15 was lying in bed
in a semi upright position. Resident 15's urinary catheter bag was hanging on the right side of the bed. It
was not covered with a dignity bag and was visible to public view.
During a follow up observation and concurrent interview with a Certified Nursing Assistant (CNA 1), on
March 16, 2022, at 1:46 PM, in Resident 15's room, Resident 15's urinary catheter bag was hanging on the
right side of the bed, uncovered and was visible to public view. CNA 1 stated Resident 15's urinary catheter
bag should be covered by a dignity bag to protect Resident 15's privacy.
During a review of Resident 15's clinical record, the face sheet (contains demographic and medical
information) indicated Resident 15 was readmitted to the facility on [DATE], with diagnoses that included
paraplegia (inability to voluntarily move the lower parts of the body), and flaccid neuropathic bladder
(bladder dysfunction wherein it becomes underactive and will not release urine at the right time).
During a concurrent interview and record review with the Infection Preventionist Nurse (IPN 2), on March
17, 2022, at 10:34 AM, the IPN 2 reviewed the facility's policy and procedure titled Quality of Life-Dignity
revised February 2020, and stated it was not followed. She further stated urinary catheter bags need to be
covered at all times to respect the resident's dignity and most importantly for infection control purposes.
During a review of the facility's policy and procedure titled Quality of Life-Dignity revised February 2020,
indicated .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff
shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter
bags covered .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
055557
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS
- resident care assessment tool) for two of 18 sampled residents (Residents 17 and 42).
Residents Affected - Few
These failures had the potential to result in unmet care needs for Residents 17 and 42, which could
adversely affect their safety and health.
Findings:
1. During an observation on March 16, 2022, at 6:51 AM, at Resident 17's room, Resident 17 was lying in
bed in an upright position, watching television.
During a review of Resident 17's clinical record, the face sheet (contains demographic and medical
information) indicated Resident 17 was initially admitted to the facility on [DATE], with diagnoses that
included liver cirrhosis (late-stage liver disease in which healthy liver tissue is replaced with scar tissue and
the liver is permanently damaged), and anxiety disorder (mental health disorder characterized by feelings
of worry, anxiety, or fear that are strong enough to interferes with one's daily activities).
During a review of Resident 17's Medication Administration Record (MAR) for January 2022, it indicated
Resident 17 had an order to receive Ativan (anti-anxiety medication) 1 milligram (mg-unit of measurement)
every eight hours as needed on January 8, 2022, at 3:44 PM. Further review indicated Resident 17
received Ativan for four days from January 15, 2022 to January 21, 2022. The dates were January 15,
2022, January 16, 2022, January 17, 2022, and January 18, 2022.
During a review of Resident 17's MDS, under Section N, Medications, dated January 21, 2022, it indicated
Resident 17 did not receive any anti-anxiety medications from January 15, 2022 to January 21, 2022.
During a concurrent interview and review of Resident 17's clinical record, with the Infection Preventionist
Nurse (IPN 2), on March 16, 2022, at 12:31 PM, the IPN 2 reviewed Resident 17's MDS dated January 21,
2022, and stated it was coded inaccurately. The IPN 2 stated, It should have been coded as a four (4) and
not zero (0), because Resident 17 received anti-anxiety medications four times from January 15, 2022 to
January 21, 2022 as indicated in his January 2022's MAR.
During a follow-up interview with the IPN 2, on March 16, 2022, at 1:03 PM, the IPN 2 reviewed the CMS's
(Centers of Medicare and Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual,
revised October 2019, and stated the RAI manual was not followed. The IPN 2 stated the resident's MAR
should thoroughly be reviewed to ensure the coding was done correctly.
During a review of the CMS's MDS 3.0 RAI Manual, revised October 2019, Page N-6, it indicated N04010B,
Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time
during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).
2. A review of Resident 42's the closed record under the MDS assessment dated [DATE], indicated she was
discharged to an acute care hospital. Further review of Resident 42's electronic health record,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
indicated multiple entries that she was discharged home.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on March 16, 2022, at 3:05 PM, with the Infection Preventionist Nurse (IPN 2), she
stated the MDS assessment was incorrect and inaccurate.
Residents Affected - Few
During a review of the CMS's MDS 3.0 RAI Manual, revised October 2019, Page 32, indicated. Any of the
following situations warrant a Discharge assessment, regardless of facility policies regarding opening and
closing clinical records and bed holds: o Resident is discharged from the facility to a private residence (as
opposed to going on an LOA);
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to implement the Registered Dietician's (RD)
recommendations for one of four residents sampled (Resident 11) when she lost 5 pounds each month
since her admission date of December 29, 2021. The RD recommended that nursing document how many
milliliters (mL) of a nutritional supplement (Resource 2.0) the resident consumed and for Resident 11 to be
seen by a Speech-Language Pathologist (SLP) for evaluation.
Residents Affected - Few
This failure had the potential to cause further impaired nutrition and weight loss in Resident 11 who is
medically compromised.
Findings:
During a review of Resident 11's admission Record, it indicated Resident 11 was admitted to the facility on
[DATE] with diagnoses of dysphagia following cerebral infarction (difficulty swallowing after suffering an
illness in which part of the brain loses its blood supply).
During a review of Resident 11's Weights and Vitals Summary, dated March 16, 2022, indicated Resident
11 weighed:
155 pounds on January 2, 2022
150 pounds on February 1, 2022 (5 pounds weight lost)
145 pounds on March 9, 2022 (5 pounds weight lost)
During an observation on March 16, 2022, at 9:22 AM, Resident 11 was sleeping in her bed, but was easily
arousable. When Resident 11 was asked how she was doing, she was unable to answer appropriately.
Resident 30 (her roommate) stated Resident 11 does not eat her food.
During an interview and review of Resident 11's clinical record on March 16, 2022, at 9:43 AM, with the
Director of Nursing (DON), the DON stated there was no order for an SLP evaluation.
During a concurrent interview and record review, on March 16, 2022, at 11:47 AM, with the RD, Resident
11's Medication Administration Record (MAR), for March 2022 was reviewed. The MAR indicated, from
March 1, 2022 to March 15, 2022, the mL of Resource 2.0 had not been documented, only a checkmark
with the nurse's initials that it had been administered. RD stated that the order was entered into the
electronic record incorrectly and did not enable the nurses to document mL consumed. She stated that
during the interdisciplinary team (IDT) meeting for Resident 11, the RNs reported that the resident
pocketed her food (holding food in the mouth for an extended amount of time without swallowing). She
stated that the DON, Dietetic Services Supervisor (DSS), and Social Worker (SW) were present during this
meeting. She thought that the DON would follow up with her recommendation for the SLP evaluation.
During a review of Resident 11's Progress Notes: IDT - Weight Committee Note, dated February 22, 2022,
indicated RD recommendations 1.) Nursing to document ml (milliliters) of resource 2.0 consumed .3.) SLP
assessment recommended r/t (related to) nursing report of pt (patient) pocketing food in mouth. The notes
further indicated those in attendance included DON, RD, DSS, and SW.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During a review of Resident 11's Order Summary Report, dated March 16, 2022, indicated Resource 2.0
three times a day for Malnutrition Risk, 120 mL: Order Date 01/05/2022.
During a review of the facility's policy and procedure (P&P) titled, Consultants, (undated), indicated
Consultants provide the Administrator with written, dated, and signed reports of each consultation visit.
Such reports contain the consultant's recommendations; plans for implementation of his/her
recommendations; findings; and plans for continued assessments. The facility retains the professional and
administrative responsibility for all services provided by consultants.
Event ID:
Facility ID:
055557
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure narcotics (government controlled medication due to
its addictive nature) used to relieve pain was signed on the resident's electronic medication administration
record (E-MAR) as given for one of eighteen sampled resident (Resident 33).
This failure had the potential for drug diversion, theft, and loss of the controlled medication that could affect
the health and safety of Resident 33.
Findings:
During the review of Resident 33's Face Sheet, (which contains resident demographic and medical
information) indicated, the resident was admitted on [DATE], with the diagnoses of Paraplegia (the loss of
ability to move parts of the body), anxiety (mental health disorder, feelings of worrying), and muscle spasm.
During a review of Resident 33's physician orders, dated, March 2022, indicated
Hydrocodone/Acetaminophen 10/325 mg (narcotic pain medication), give one tablet by mouth every six
hours as needed for severe pain.
During a review of the facility's Controlled Medication Count Sheet, indicated, hydrocodone/acetaminophen
10/325 mg, (controlled medication used to relieve pain) was taken out for Resident 33 on March 16, 2022,
at 4:00 AM. A review of Resident 33's Electronic Medication Administration Record (E-MAR), indicated,
there was no documentation and signature of the medication nurse that specified pain medication was
given on March 16. 2022 at 4:00 AM
During a concurrent interview and record review, on March 16, 2022, at 1:05 PM with the Infection
Preventionist Nurse (IPN 1), she stated Resident 33's Hydrocodone/Acetaminophen 10/325 mg should
have been charted timely as given on Resident 33's E-MAR when signed out in the Controlled Medication
Count Sheet on March 16, 2022 at 4:00 AM.
During an interview with the Director of Nursing (DON), on March 16, 2022, at 1:16 PM, she stated,
narcotics taken from the narcotic drawer should be recorded on the Controlled Medication Count Sheet and
documented as given on the resident's eMAR in timely manner.
The facility's policy titled, Controlled Drugs, date revised unknown, indicated, Policy: Drugs with high abuse
potential will be subject to special handling, storage, disposal, and record keeping .Procedures: SS. The
nurse has to enter the following information on the narcotic drug record immediately after a dose of a
controlled drug is administered: 1. Date and time of administration, 2. Dose administered .3. Signature of
the nurse that administered the dose.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure that medication was
secured to be administered per the facility policy, when Silvadene Cream® (a topical medication used
commonly on wounds to prevent and treat infections) was left unattended on the bedside table of one out of
18 sampled residents (Resident 12).
This had the potential to cause harm due to medication being accessible to staff and residents who lacked
knowledge, training, and the necessary qualifications to administer medication.
Findings:
During an observation on March 14, 2022, at 9:10 AM, in the resident's room, it was noted that Silvadene
cream® had been left unattended on the bedside table next to Resident 12.
During an interview on March 14, 2022, at 9:12 AM, with Resident 12, he stated, That's [name of
Registered Nurse] (RN1), she left the cream. she's too lazy to put it on me herself, so she leaves it there for
the CNA (certified nursing assistant) to apply it.
During an interview on March 14, 2022, at 9:18 AM, with a certified nursing assistant (CNA 1), she stated
the medication should have been taken away by the nurse, it shouldn't have been left there, CNAs are not
allowed to give medications.
During an interview on March 14, 2022, at 9:25 AM, with a Licensed Vocational nurse LVN 4, she stated
that she is not sure why it was left there, it should not be left unattended.
During an interview on March 14, 2022, at 9:35 AM, with the Director of Nursing (DON), she stated that
medication should never be left unattended on a resident's bedside table.
During an interview on March 14, 2022, at 9:50 AM, with RN1, she stated that she had not seen Resident
12 today. She had seen him yesterday, but she was not sure if she had left the medication on his bedside
table.
During a record review of the facility policy titled, Administrating Medications with a revision date of April
2019, detailed, .1. Only persons licensed or permitted by this state to prepare, administer and document
the administration of medications may do so .19. During administration of medications, the medication cart
is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the
personnel administering medications, and all outward sides must be inaccessible to residents or others
passing by.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review, the facility failed to follow their daily menu for lunch on
March 15, 2022, by substituting the penne pasta with mashed potatoes for three of three puree (food is
blended until it is a thick, smooth, lump-free consistency) lunch trays. Puree mashed potatoes were also
served according to the menu on March 14, 2022.
This failure had the potential for residents to lose their appetite because they were served the same starch
two times in a row, which could compromise the nutritional status of three of three residents (Residents 6,
11, and 28) who are medically compromised.
Findings:
During a concurrent observation and interview on March 15, 2022, at 1:10 PM, with the Dietetic Services
Supervisor (DSS), in the hallway directly outside of the kitchen, the lunch test trays for the regular and
puree diet were observed to have two different food items. The regular lunch tray had penne pasta and the
puree tray had mashed potatoes. The DSS stated the cook should follow the menu and the spreadsheet for
the regular and puree diet.
During a subsequent interview with the DSS on March 15, 2022, at 1:15 PM, the DSS stated the cook
served mashed potatoes today (March 15, 2022), but it should have been puree penne pasta, according to
the spreadsheet.
During a review of Recipe: Penne with Garlic and Herbs: Week 2 Tuesday, indicated, Special Diets:
Pureeds: Puree and serve #8. (#16 to small and ¾ cup to large).
During a review of a facility document titled Cooks Spreadsheet, dated March 15, 2022, indicated on
Tuesday March 15, 2022, the puree diets should receive puree penne pasta.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, interview, and record review, the facility failed to ensure the proper consistency of
the spinach served on the puree (food is blended until it is a thick, smooth, lump-free consistency) lunch
trays for three of three residents (Residents 6, 11, 28).
This failure had the potential to cause difficulties in swallowing and possible aspiration (when something
swallowed enters the airway or lungs) in these medically compromised residents.
Findings:
During a concurrent observation and interview on March 15, 2022, at 10:55 AM, with Kitchen Aide (KA), in
the kitchen, the KA was observed preparing pureed meatballs for lunch. She stated the pureed should be
the consistency of ice cream or mashed potatoes.
During a concurrent observation and interview on March 15, 2022, at 1:10 PM, with the Dietetic Services
Supervisor (DSS), in the hallway directly outside the kitchen, the spinach on the puree lunch test tray was
watery in consistency and spread out on the plate. The DSS stated that it should not be like that, it should
be thicker.
During a review of a facility document titled, Regular Pureed Diet, dated 2020, indicated The texture of the
food should be of a smooth and moist consistency and able to hold its shape.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and record review, the facility failed to prevent entry of outside
contaminants into the bulk container of thickener (a starch added to liquids and foods to make it firmer).
Residents Affected - Many
This failure had the potential to cause contamination of food prepared with thickener, and possible
foodborne illness in 47 of 48 medically compromised residents who received food from the kitchen.
Findings:
During a concurrent observation and interview on March 14, 2022, at 8:26 AM, with the Dietetic Services
Supervisor (DSS), in the kitchen, the bulk container of thickener had multiple dark crumbs mixed in with the
white thickener. The DSS stated that the thickener should not be like that.
During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 3-701.11 indicates A
food that is unsafe, adulterated, or not honestly presented . shall be discarded or reconditioned according
to an approved procedure. In addition, 3-201.11 indicates, it is also critical to monitor food products to
ensure that, after harvesting and processing, they do not fall victim to conditions that endanger their safety,
make them adulterated, or compromise their honest presentation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility did not properly dispose of trash when the
outside garbage bin for trash was overflowing, and the lid was not closed for one of one dumpster.
Residents Affected - Many
This failure had the potential to attract vermin (pests or nuisance animals that spread diseases) in a facility
that cares for 48 medically compromised residents.
Findings:
During a concurrent observation and interview on March 14, 2022, at 10:43 AM, with the Dietetic Services
Supervisor (DSS), in the outdoor garbage storage area, the trash dumpster was overflowing with garbage,
and the lids were not closed. The DSS stated that the trash should not be overflowing, and the lids should
be closed.
During a review of the facility's policy and procedure (P&P) titled, Sanitation: Garbage and Trash, dated
2018, indicated, Garbage and trash cans must be inspected daily that no debris is on the ground or
surrounding area, and that the lids are closed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure infection control practices were
established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the
possible development and transmission of a Coronavirus, COVID-19 (a highly contagious respiratory
infection) when, three nursing staff were observed not following proper personal protective equipment, PPE
(equipment and cloths for protection against infectious diseases) guidelines when entering rooms in yellow
zone (Residents under isolation observation for suspected COVID-19).
Residents Affected - Some
This failure had the potential to result in the spread of Coronavirus (COVID-19) infection to 48 medically
compromised residents.
Findings:
During an observation on March 14, 2022, at 10:35 AM, in room102, an isolation room, a Licensed
Vocational Nurse (LVN 2) was entering a room without wearing an N-95 respirator.
During an observation on March 14, 2022, at 11:00 AM, in room [ROOM NUMBER], a resident in the yellow
zone, insolation room, the Infection Preventionist Nurse (IPN 1) was entering the room without the N-95
respirator. She was wearing a surgical mask.
During an observation on March 14, 2022, at 11:15 AM, near room [ROOM NUMBER], a resident in the
yellow zone isolation room, a certified nursing assistant (CNA 5) was observed entering the room without
the N-95 respirator and was wearing surgical mask.
During an interview with the LVN 2 on March 14, 2022, at 11:20 AM, she stated yellow zone isolation room
does not require wearing a N-95 respirator unless it involves bodily fluids. The LVN 2 said red zone
(confirmed covid-19) will require a N-95 respirator but isolation rooms for suspected covid-19 require a
surgical mask.
During an interview with the IPN 1 on March 14, 2022, at 11:30AM, the IPN 1 stated N-95 respirator is
needed for red zone (covid positive rooms), N-95 is not needed for the yellow isolation rooms.
During an interview with the CNA 5 on March 14, 2022, at 11:40 AM, the CNA stated N-95 respirator was
needed to be worn on the yellow zone isolation room, however, she was observed to wearing a surgical
mask.
During an interview with the Director of Nursing (DON) on March 14, 2022, at 3:09 PM, the DON stated
N-95 respirator should be used instead of surgical mask for the rooms within the yellow zone.
During a review facility's policy titled, Policy and Procedure on Quarantine for Healthcare Personnel (HCP)
Exposed to SARS-Cov-2 and return to work for HCP with COVID-19, reviewed and approved on March 08,
2022, indicated, Procedure: F. The facility shall make N-95 respirators available to any HCP for the care of
residents with suspected or confirmed COVID-19.
According to the Centers for Disease and Prevention (CDC), Infection Control Guidance, dated February 2,
2022, indicated, the following recommendations for: Personal Protective Equipment: HCP who enter the
room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye
protection (i.e., goggles or a face shield that covers the front and sides of the face).
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055557
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Post Acute
35253 Avenue H
Yucaipa, CA 92399
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, and record review, the facility failed to implement an antibiotic stewardship program (an
effort to measure and improve how antibiotics are prescribed by physicians and used by residents) when
Resident 29 was prescribed antibiotics and there were no criteria used to ensure that they had been
prescribed appropriately.
Residents Affected - Some
This failure had a potential to ineffectively treat infections, protect patients from harm caused by
unnecessary antibiotic use and combat antibiotic resistance, for one resident reviewed for antibiotics.
Findings:
During a review of Resident 29's medication orders, it was noted that he had been prescribed Keflex (a
medication used for infections) 500 mg (mg-unit of measurement) twice a day. There was no evidence that
he had been screened and met criteria for antibiotic use per the facility policy.
During an interview on March 16, 2022, at 9:47 AM, with a Licensed Vocational Nurse (LVN 3), she stated
the physician orders antibiotics, but I don't know what an antibiotic stewardship program is.
During an interview on March 17, 2022, at 1:20 PM, with the Director of Nursing (DON), she stated they do
not have an antibiotic stewardship program currently. She was unable to provide any documentation to
show that the facility had addressed the antibiotic order and justification for use, for Resident 29.
During a record review of the facility policy titled, Antibiotic Stewardship with a revision date of December
2016, indicated, Antibiotics will be prescribed and administered to residents under the guidance of the
facility's Antibiotic Stewardship Program .The staff and practitioner will document the specific criteria that
support the suspicion in the resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055557
If continuation sheet
Page 14 of 14
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Back to topCitations
26 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0009GeneralS&S Dpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Dpotential for harm
Address subsistence needs for staff and patients.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Dpotential for harm
Implement emergency and standby power systems.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0373GeneralS&S Dpotential for harm
Have enough space near smoke barriers to protect residents.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
FAQ · About this visit
Common questions about this visit
What happened during the March 17, 2022 survey of Creekside Post Acute?
This was a inspection survey of Creekside Post Acute on March 17, 2022. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Creekside Post Acute on March 17, 2022?
Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Include a process for Emergency Preparedness collaboration."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.