Creekside Post-Acute: Infection Control Failure - CA
The lapse was straightforward. At 3:05 p.m. on August 21, inspectors watched CNA B enter the room of Resident 2, pull on gloves, and help her with care. Then she peeled off the gloves and walked out. No hand sanitizer. No soap and water. Straight into the hallway.
Resident 2 had been admitted to the facility and was receiving icing treatment on her knee at least four times a day, twenty minutes each session, to manage pain and swelling. She had asked CNA B to fix an ice wrap that had slid out of place. CNA B repositioned it and left.
When inspectors spoke with CNA B on the spot, she didn't dispute what had happened. She said the resident had asked her to fix the sliding ice wrap, so she pulled it back up and repositioned it. Then she acknowledged what she hadn't done. "She stated she should sanitize her hands when walking out of Resident 2's room," the inspection report noted.
That was it. No confusion about what the expectation was. She knew.
The facility's own hand hygiene policy, in place since August 2019, is explicit on this point. Staff are required to use an alcohol-based hand rub or soap and water before and after direct contact with residents, and after removing gloves. The policy states directly that wearing gloves does not replace hand washing.
The infection preventionist, interviewed by inspectors on September 23, the day of the inspection, confirmed the same thing. Staff should sanitize their hands when leaving residents' rooms. Full stop.
Federal inspectors cited the facility under F0880, which covers infection prevention and control. The violation was tagged at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than documented injury. Only a few residents were identified as affected.
That classification matters in terms of how CMS scores and penalizes a facility, but it doesn't change what the moment looked like: a staff member finished direct contact with a resident, removed contaminated gloves, and moved into a shared hallway where other residents, visitors, and staff circulate, without taking the ten seconds required to sanitize.
Infection control lapses in nursing homes carry particular weight because the population living in them is already medically compromised. Residents with wounds, surgical recovery needs, weakened immune systems, or chronic conditions are more vulnerable to pathogens that a healthy person might shake off. A hallway is not a contained space. Hands that touch a call button, a door handle, a railing, or another resident after leaving a care encounter without sanitizing become a transmission route.
The inspection that captured this violation was a complaint inspection, meaning someone, whether a resident, family member, or staff, had contacted regulators before inspectors arrived. The report does not specify what the original complaint alleged.
Creekside Post-Acute's own written policy gave CNA B everything she needed to know. The infection preventionist confirmed the standard on the same day inspectors asked about it. The gap was not a knowledge gap. It was a compliance gap, a moment where a known requirement simply didn't happen.
Resident 2 needed her ice wrap repositioned. Someone came, fixed it, and left. What didn't happen in those few seconds after the gloves came off is what brought federal inspectors to write it down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Post-acute from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 15, 2026 · Our methodology
CREEKSIDE POST-ACUTE in SAN JOSE, CA was cited for violations during a health inspection on September 23, 2025.
on August 21, inspectors watched CNA B enter the room of Resident 2, pull on gloves, and help her with care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.