Health inspection·June 7, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube- tube inserted through the abdomen into the stomach that delivers nutrition, hydration, and medications) was implemented in accordance with the facility's policy and procedure for three of six residents (Residents 18, 19, and 6) reviewed for g-tube when a Licensed Vocational Nurse (LVN 2) did not check Residents 18, 19, and 6's G-tube placement (listening to gurgling sound when flushing air through the g-tube to confirm for correct position) before administering medications. These failures had the potential to place Residents 18, 19, and 6 at increased risk of aspiration (when food or liquids enter the lungs). Findings: 1. During a review of Resident 18's admission Record (contains demographic and medical information), it indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (condition where there is not enough oxygen in the body), seizures (sudden, uncontrolled burst of electrical activity in brain), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that obstructs airflow). During a review of Resident 18's Physician Order, dated February 4, 2024, it indicated Resident 18 had an order for licensed nurses to Check tube placement/patency, Every shift; 07:00 AM - 7:00 PM - 7:00 PM 7:00 AM. A medication administration observation was conducted on June 4, 2024, at 8:01 AM, in Resident 18's room, with LVN 2. Resident 18 was lying in bed, listening to the radio, with the head of the bed elevated. LVN 2 attached a syringe onto the G-tube, checked for residual (fluid/contents that remain in the stomach), then proceeded to flush the G-tube with 30 mL (milliliters - unit of measurement) of water and administered cranberry (supplement) 425 mg (milligram - unit of measurement). LVN 2 did not check for G-tube placement. 2. During a review of Resident 19's admission Record, it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included sepsis (a body's extreme reaction to infection), cerebral infarction (reduced blood flow to brain by narrowed vessels), and encephalopathy (group of conditions that cause brain dysfunction). During a review of Resident 19's Physician Order, dated April 17, 2024, it indicated Resident 19 (continued on next page) 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 7 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 06/07/2024 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)