Other·August 14, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00596360. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 34328 HFEN, 40019 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop a comprehensive care plan on safe bed mobility for one resident (Resident 1), for a census of 65. This failure resulted in having no clear directions for care for safe mobilization and repositioning techniques for Resident 1. Findings: Resident 1 was admitted in early 2014 with diagnoses including dementia, obesity, and primary generalized osteoarthritis. Resident 1 was reported by the facility to have a witnessed fall on 7/22/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A Review of the Minimum Data Set (MDS, an assessment tool) for Resident 1, dated 1/2/18, 3/24/18, and 6/19/18, indicated, "Bed mobility ... 1. ADL [Activities of Daily Living] SelfPerformance ... Extensive assistance ... 2.Support ... Two+ persons physical assist ..." A Review of Resident 1's care plan on ADL care, revised 11/8/17, did not specify appropriate interventions for safe mobility in bed and transfers. The care plan intervention that indicated "2 person assist with bed mobility, transfers ..." was not initiated until 7/23/18. During an interview with the Director of Staff Development (DSD) on 10/3/18 at 11:25 a.m., the DSD stated care plans are updated with any change of condition and reviewed quarterly. The DSD further stated MDS assessments are done initially, quarterly, annually, and during any significant change of condition. DSD stated the MDS Coordinator or a licensed nurse updates the care plans based on the assessments conducted. During an interview with the MDS Coordinator on 10/11/18 at 2:45 p.m., the MDS Coordinator confirmed the care plan intervention on 2person assist for Resident 1 was initiated on 7/23/18. A Review of the document titled, "PersonCentered Care Plan", revision date 3/1/18, indicated, "Care plans will be ... Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interviews and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident 1), who required two-person assistance for bed mobility, for a census of 65. This failure resulted in Resident 1 having an avoidable fall with injuries (a scalp abrasion [scraping of the surface layer of the skin] and a scalp contusion [bruise]). Findings: A review of Resident 1's "Admission Record" revealed she was admitted to the facility in early 2014 with diagnoses including dementia, obesity, and primary generalized osteoarthritis. A Review of the Minimum Data Set (MDS, an assessment tool) for Resident 1, dated 6/19/18, indicated, "Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture ... 1. ADL [Activities of Daily Living] Self-Performance ... Extensive assistance ... 2. Support ... Two+ persons physical assist ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the document titled, PT (Physical Therapy) Initial Evaluation for Resident 1, dated 7/20/15, indicated "Pt. [patient] is dependent for all functional mobilities and is non-ambulatory ... impaired ADL [Activities of Daily Living] performance, impaired cognitive [thinking] skills, impaired functional activity tolerance, impaired balance, impaired postural alignment, impaired strength, impaired transfers ... Bed Mobility = dependent". A review of Resident 1's Care Plan, revised 11/8/17, indicated, "Resident is dependent for ADL care in ... grooming, dressing, bed mobility ... due to cognitive loss/dementia." A review of Resident 1's Progress Notes dated 7/22/18, indicated, "On monitoring for S/P [status post; condition after] witnessed fall while CNA [Certified Nurse Assistant] rendering hands on care to res [resident], sustained bump at the back of head ..." A review of Resident 1's Progress Notes dated 7/23/18, indicated, "Resident slid off her bed and landed on the floor mat yesterday morning while C.N.A. [Certified Nurse Assistant] was rendering hands-on care to her. She sustained a bump and a small cut (.08 cm) on the back of her head as a result. She was transported to [name of hospital] for evaluation." During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/2/18 at 10:00 a.m., LVN 1 stated Resident 1 was a two-person assist for provision of incontinent care. During an interview with the Director of Nursing (DON) on 8/2/18 at 10:10 a.m., the DON stated that when providing care to Resident 1, "Ideally, you really should have two-person assist." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with CNA 2 on 8/2/18 at 10:18 a.m., CNA 2 stated that providing incontinent care to Resident 1 required two persons to assist. During an interview with CNA 1 on 8/2/18 at 11:00 a.m., CNA 1 stated that he was providing care to Resident 1 on 7/22/18 and was cleaning her up while in bed when Resident 1 fell. CNA 1 stated, "When I changed her, I rolled her towards me, put briefs on, turned her back and she slid." CNA 1 further stated resident has an "inflatable mattress" and that he found the mattress very slippery. A review of a Physician Order dated 7/22/18, indicated, "Transfer to [name of hospital] - ER [Emergency Room] for evaluation", and "Neuro check per facility protocol." A review of the document titled, "Emergency Documentation" from [name of hospital] Emergency Department, dated 7/22/18, indicated, "Diagnosis:... Scalp abrasion; Scalp contusion." A review of the facility policy titled, "Falls Management," revised 3/15/16, indicated, "Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury ... Develop individualized plan of care ... Review and revise care plan regularly ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E2HZ11 Facility ID: CA030000826 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555387 (X3) DATE SURVEY COMPLETED 08/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE CENTER 9107 Davis Road Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: E2HZ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000826 (X5) COMPLETE DATE If continuation sheet 7 of 7