Health inspection·February 12, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Certified Nursing Assistant (CNA) 1 told Resident 1, I could kill you. Residents Affected - Few This failure resulted in verbal abuse and potential psychological harm for Resident 1. Findings: Review of a facility reported incident received on 1/28/24, indicated, .RESIDENTS . [Resident 1] .Alleged Perpetrator . [CNA 1] . Date of Alleged Event: 01/26/2024 .Resident reported to nurse that on Friday, CNA made statement, I could kill you and nobody would know. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including anxiety disorder, heart failure, difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/18/24, indicated Resident 1 had intact cognition (The assessment uses a points system that ranges from 0 to 15 points, 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). During an interview on 2/12/24, at 2:52 p.m., CNA 2 stated either on January 26th or 27th, CNA 1 called her to Resident 1's room to assist with his care. CNA 2 stated CNA 1 and Resident 1 were talking when CNA 1 told Resident 1, I will kill you. During an interview on 2/12/24, at 3:26 p.m., Licensed Nurse (LN) 1 stated Resident 1 informed her on Sunday, 1/28/24, around 4:15 p.m. that CNA 1 told him on Friday 1/26/24, that, I can kill you and get away with it. LN 1 stated Resident 1 told her that he did not tell anyone about it until he told her. LN 1 stated Resident 1 told her that when CNA 1 made the comment, CNA 2 was in his room's doorway, exiting the room. LN 1 stated Resident 1 told her that he did not know if CNA 1 heard it or not. LN 1 stated CNA 1 was working on 1/28/24 and she confronted CNA 1. LN 1 further stated CNA 1 confirmed she did say that and was just joking. LN 1 stated Resident 1 told her that CNA 1 did not have a joking face when she made the comment. LN 1 added Resident 1 told her that CNA 1 went back to him an hour later and apologized and said she was kidding but she did not say that right away. LN 1 stated Resident 1 was very upset. LN 1 stated the words CNA 1 chose to use were very threatening. LN 1 stated when she informed Resident 1 that they took CNA 1 off the schedule, Resident 1 was very Page 1 of 6 555387 555387 02/12/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0600 appreciative and was relieved. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 2/12/24, at 4:56 p.m., Resident 1 stated CNA 1 came up to his bed and was mad because he was pressing his call light too much. Resident 1 stated CNA 1 told him, Do you know I can kill you in your sleep and no-one would know nothing. Resident 1 stated he told her to get out of his room. Resident 1 stated later CNA 1 came back to apologize. Resident 1 added, I told her to get out of my room. I was scared for my life. I was getting nightmares because of this lady. I got nightmares that she came to my bed and had bullet on my forehead. Resident 1 further stated, I was scared she was going to come back and hurt me, that's why I left the facility. I couldn't even walk. Resident 1 stated he was very upset about the comment made to him by CNA 1. Residents Affected - Few During a phone interview on 2/13/24, at 3:11 p.m., CNA 1 stated on Friday 1/26/24, in Resident 1's room, herself and CNA 2 were providing care to Resident 1 when she told Resident 1, I could kill you. CNA 1 stated she did not say, no-one would ever know. CNA 1 stated they were joking around, nobody was upset, nobody was mad. CNA 1 stated it just came out of her mouth and she didn't mean to say it. CNA 1 stated she apologized to him when she went back to answer his call light again. CNA 1 stated Resident 1 told her it was ok, and he already forgot about it. CNA 1 stated on Sunday morning, she heard from another CNA that Resident 1 was upset about it. CNA 1 stated the Director of Nursing (DON) called her on Sunday and told her the facility had to do an investigation into the allegation and the comment she made was verbal abuse towards Resident 1, and she was taken off the schedule. During a concurrent interview with the Administrator (ADM) and the DON on 2/12/24, at 5:58 p.m., the DON stated LN 1 informed her on 1/28/24, that Resident 1 voiced that CNA 1 made a statement that she would kill him, and no one will know about it. The ADM stated on Sunday 1/28/24, around 4 p.m., he received a call from the DON that Resident 1 claimed CNA 1 told him, I can kill you and no one would know about it. The ADM stated he came to the facility the same day and spoke with Resident 1. The ADM stated Resident 1 told him that on Friday 1/26/24, CNA 1 was providing care to him and made that statement. The ADM stated Resident 1 told him that CNA 1 came in later and apologized to him. The ADM stated CNA 2 witnessed the incident. The ADM stated CNA 1 made an inappropriate comment to Resident 1 and that was not acceptable. Review of Resident 1's Change in Condition Evaluation record dated 1/28/24, indicated, .PATIENT ACCUSED A CNA VERBALIZED INAPPROPRIATE VERBIAGE [words] TO THE PATIENT. PT [patient] REPORTED TO NURSE. NURSE REPORTED TO ADMINISTRATOR AND DON. CNA TOOK OFF ASSIGNMENT, IMMEDIATELY .PT AWARE OF ALL ACTIONS BEING TAKEN AND APPRECIATES THE EFFORTS . Review of Resident 1's record titled Follow-up Documentation dated 1/29/24, indicated, .Resident is on monitoring for accusation of inappropriate verbiage day #1. Nurse spoke to resident, resident reported having a stressful past few days and reported chest pain .Resident reported feeling anxious and stressed Review of Resident 1's Social Services note dated 1/29/24, indicated, Followed up with resident regarding incident .Resident verbalized still feeling stressed over incident .He was appreciative for writer following up and talking with him. He would like to coordinate discharge for tomorrow if possible .Writer encouraged him to express his feelings and concerns to staff when needed . Review of Resident 1's Social Services note dated 1/30/24, indicated, Resident discharged home .on 1/30/24 .Health/wound teachings and medication reviewed with resident by LN. Wheelchair was ordered and delivered to facility . prior to discharge .Discharge was resident driven, risk vs [versus] 555387 Page 2 of 6 555387 02/12/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0600 benefits explained to resident .Resident sent with 5 days of wound care supplies . Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse Prohibition Policy and Procedure dated 2/23/21, indicated .HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents .Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that he/she will never be able to see his/her family again .The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, and involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property . Residents Affected - Few 555387 Page 3 of 6 555387 02/12/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility staff failed to report an abuse allegation for one of three residents (Resident 1), when Certified Nursing Assistant (CNA) 2 witnessed CNA 1 telling Resident 1 that she could kill him on 1/26/24 . This failure resulted in delayed immediate protection of Resident 1 and a delayed investigation of the alleged abuse and placed other residents in the facility at risk of abuse. Findings: Review of a facility reported incident received on 1/28/24 at 5:31 p.m., indicated, .RESIDENTS . [Resident 1] .Alleged Perpetrator . [CNA 1] . Date of Alleged Event: 01/26/2024 .Resident reported to nurse that on Friday, CNA made statement, I could kill you and nobody would know. Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including anxiety disorder, heart failure, difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/18/24, indicated Resident 1 had intact cognition (The assessment uses a points system that ranges from 0 to 15 points, 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). During an interview on 2/12/24, at 2:52 p.m., CNA 2 stated either on January 26th or 27th, CNA 1 called her to Resident 1's room to assist with his care. CNA 2 stated CNA 1 and Resident 1 were talking when CNA 1 told Resident 1, I will kill you. CNA 2 stated at that time she did not think it was an inappropriate comment since CNA 1 was smiling and seemed to be joking around. CNA 2 stated she did not inform anyone of the comment made to Resident 1. CNA 2 stated later, she was approached by the Director of Nursing (DON) who informed her of the different types of abuse and the importance of reporting abuse. CNA 2 stated she took responsibility for not reporting and learned from the incident. CNA 2 stated she was informed that Resident 1 reported the incident to facility staff on 1/28/24. During an interview on 2/12/24, at 3:26 p.m., Licensed Nurse (LN) 1 stated Resident 1 informed her on Sunday, 1/28/24, around 4:15 p.m. that CNA 1 told him on Friday 1/26/24, that, I can kill you and get away with it. LN 1 stated Resident 1 told her that he did not tell anyone about it until he told her. LN 1 stated Resident 1 told her that when CNA 1 made the comment, CNA 2 was in Resident 1's doorway, exiting the room. LN 1 stated Resident 1 told her that he did not know if CNA 1 heard it or not. LN 1 stated CNA 1 was working on 1/28/24 and she confronted CNA 1. LN 1 further stated CNA 1 confirmed she did say that but was just joking. LN 1 stated Resident 1 told her that CNA 1 did not have a joking face when she made the comment. LN 1 added Resident 1 told her that CNA 1 went back to him an hour later and apologized and said she was kidding but she did not say that right away. LN 1 stated Resident 1 was very upset. LN 1 stated the words CNA 1 chose to use were very threatening. LN 1 stated when she informed Resident 1 that they took CNA 1 off the schedule, Resident 1 was very appreciative and was relieved. During a phone interview on 2/12/24, at 4:56 p.m., Resident 1 stated CNA 1 came up to his bed and 555387 Page 4 of 6 555387 02/12/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was mad because he was pressing his call light too much. Resident 1 stated he did not remember the exact date and time but it was towards the end of January around 4 p.m., on a Wednesday or Thursday. Resident 1 stated CNA 1 told him, Do you know I can kill you in your sleep and no-one would know nothing. Resident 1 stated he told CNA 1 to get out of his room. Resident 1 stated later CNA 1 came back to apologize. Resident 1 added, I told her to get out of my room. I was scared for my life. I was getting nightmares because of this lady. I got nightmares that she came to my bed and had bullet on my forehead. Resident 1 further stated, I was scared she was going to come back and hurt me, that's why I left the facility. I couldn't even walk. Resident 1 stated he was very upset about the incident. During a phone interview on 2/13/24, at 3:11 p.m., CNA 1 stated on Friday 1/26/24, in Resident 1's room, herself and CNA 2 were providing care to Resident 1 when she told Resident 1, I could kill you. CNA 1 stated she did not say, no-one would ever know. CNA 1 stated they were joking around, nobody was upset, and nobody was mad. CNA 1 stated it just came out of her mouth and she didn't mean to say that. CNA 1 stated she apologized to him when she went back to answer his call light again. CNA 1 stated Resident 1 told her it was ok, and he already forgot about it. CNA 1 stated on Sunday morning, she heard from another CNA that Resident 1 was upset about it and did not like the comment made. CNA 1 stated the DON called her on Sunday and told her that the facility had to do an investigation into the alleged verbal abuse against Resident 1, and she was taken off the schedule. During a concurrent interview with the Administrator (ADM) and the DON on 2/12/24, at 5:58 p.m., the DON stated LN 1 informed her on 1/28/24, that Resident 1 voiced that CNA 1 made a statement that she will kill him, and no one would know about it. The ADM stated on Sunday 1/28/24, around 4 p.m., he received a call from the DON that Resident 1 claimed CNA 1 told him, I can kill you and no one would know about it. The ADM stated he came to the facility the same day and spoke with Resident 1. The ADM stated Resident 1 told him that on Friday 1/26/24, CNA 1 was providing care to him and made that statement. The ADM stated Resident 1 told him that CNA 1 came in later and apologized to him. The ADM stated the incident happened on Friday 1/26/24, but no one reported it until Resident 1 himself reported it to LN 1 on Sunday 1/28/24. The ADM stated CNA 2 witnessed the incident. The ADM further stated CNA 2 thought they were joking around and the comment was not serious. The ADM stated staff should report abuse allegations immediately. The ADM stated CNA 2 should have reported it immediately even if she thought it was a joking matter to make sure Resident 1 was safe. The ADM stated not reporting abuse could cause harm to the residents. The ADM stated CNA 1 made an inappropriate comment to Resident 1 and that was not acceptable. Review of Resident 1's Change in Condition Evaluation record dated 1/28/24, indicated, .PATIENT ACCUSED A CNA VERBALIZED INAPPROPRIATE VERBIAGE [words] TO THE PATIENT. PT [patient] REPORTED TO NURSE. NURSE REPORTED TO ADMINISTRATOR AND DON. CNA TOOK OFF ASSIGNMENT, IMMEDIATELY .PT AWARE OF ALL ACTIONS BEING TAKEN AND APPRECIATES THE EFFORTS . Review of Resident 1's record titled Follow-up Documentation dated 1/29/24, indicated, .Resident is on monitoring for accusation of inappropriate verbiage day #1. Nurse spoke to resident, resident reported having a stressful past few days and reported chest pain .Resident reported feeling anxious and stressed Review of Resident 1's Social Services note dated 1/29/24, indicated, Followed up with resident regarding incident .Resident verbalized still feeling stressed over incident .He was appreciative for writer following up and talking with him. He would like to coordinate discharge for tomorrow if possible .Writer encouraged him to express his feelings and concerns to staff when needed . 555387 Page 5 of 6 555387 02/12/2024 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's Social Services note dated 1/30/24, indicated, Resident discharged home .on 1/30/24 .Health/wound teachings and medication reviewed with resident by LN. Wheelchair was ordered and delivered to facility . prior to discharge .Discharge was resident driven, risk vs [versus] benefits explained to resident .Resident sent with 5 days of wound care supplies . Review of the facility policy titled Abuse Prohibition Policy and Procedure dated 2/23/21, indicated .HealthCare Centers prohibit abuse .Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that he/she will never be able to see his/her family again .The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse .Training and reporting obligations will be provided to all employees .Anyone who witnesses an incident of suspected abuse .is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately .The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation .All reports of suspected abuse must also be reported to the patient's family and attending physician Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following . Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made .Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries and other agencies as required Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported .Initiate an investigation within 2 hours of an allegation of abuse that focuses on .whether abuse or neglect occurred and to what extent; Abuse Prohibition Policy and Procedure .clinical examination for signs of injuries, if indicated . causative factors; and Interventions to prevent further injury . 555387 Page 6 of 6