Creekside Post-acute

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the residents received the necessary care and services for one of three residents (1) when the wound doctor's order for Resident 1's venous ulcer (open sores that occur when the veins in the legs do not push blood back up to the heart as well as they should)

on his right lower lateral leg was not carried out to the treatment administration record (TAR). This failure had the potential for Resident 1's wound did not receive the treatment, became deteriorated, and delayed wound healing.Findings:Review of Resident 1's admission Record indicated he was admitted to the facility

on [DATE REDACTED] with chronic venous hypertension (increased pressure inside the veins) with ulcer of bilateral lower extremity diagnosis.Review of Resident 1's Skin Assessment and IDT - Skin Integrity, dated 8/5/25, indicated Resident 1 received a treatment order from the wound doctor for the licensed nurse to cleanse

the venous ulcer on his right lower lateral leg with normal saline (0.9 grams [g, a metric unit of mass] of salt per 100 milliliters [ml, a metric unit of volume] of solution), apply Xeroform (a sterile, non-adhering protective dressing), and cover with dry dressing and Kerlix (soft gauze roll).However, review of Resident 1's 8/2025 TAR indicated the treatment order was not recorded.During an interview with treatment nurse A (TMN A) on 8/22/25, at 3:10 p.m., she reviewed Resident 1's Wound Docs Preliminary Wound Report, dated 8/5/25, and Resident 1's 8/2025 TAR and confirmed that the wound doctor's order for Resident 1's venous ulcer on his right lower lateral leg was not carried out to the TAR. TMN A confirmed that Resident 1 still had the venous ulcer on his right lower lateral leg and stated the wound might not receive the treatment as ordered if the order was not on the TAR for the licensed nurse to follow.Review of the facility's policy, Medication and Treatment Orders, dated 7/2016, indicated . 3. Drug and biological orders must be recorded

on the physician's order sheet in the resident's chart.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Creekside Post-Acute

3580 Payne Avenue San Jose, CA 95117

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 implement infection control practices when certified nursing assistant B (CNA B) walked out of Resident 2's room and in the hallway without sanitizing her hands. This failure had the potential to spread infection in the facility.Findings:Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE REDACTED].Review of Resident 2's physician order, dated 8/4/25, indicated she had an order for ice the knee at least 4 times per day for 20 minutes each time to help reduce pain and swelling.During an observation on 8/21/25, at 3:05 p.m., CNA B entered Resident 2's room, put on gloves, and helped Resident 2; then CNA B removed her gloves, walked out of Resident 2's room and in the hallway without sanitizing her hands.During a concurrent interview with CNA B, she stated Resident 2 asked her to fix the ice wrap on her knee because it was sliding down, so she pulled the ice wrap up and repositioned it for Resident 2. CNA B stated she should sanitize her hands when walking out of Resident 2's room.During an interview with the infection preventionist (IP) on 9/23/25, at 1:05 p.m., she stated the staff should sanitize their hands when walking out of the residents' rooms.Review of

the facility's policy, Handwashing/Hand Hygiene, dated 8/2019, indicated . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . b. Before and after direct contact with residents; . m. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet