Health inspection·October 2, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 10/2/24 at 3:13 p.m. with Licensed Nurse (LN) 4, LN 4 stated she was assigned to care for Resident 1 on 8/26/24 for the morning shift. LN 4 stated Resident 1 ' s family member (FM) visited on 8/26/24 in the morning and found Resident 1 had vomited. LN 4 stated Resident 1 ' s FM was upset that there was no suction machine at the bedside to remove the vomited liquid and secretions from his mouth. LN 4 stated she brought one in and suctioned Resident 1, and stated, there were a lot of secretions. LN 4 stated Resident 1 ' s condition was declining. LN 4 reviewed Resident 1 ' s clinical record and stated she did not document Resident 1 ' s change of condition in his record, and there were no further vital signs checked after 11:38 am. LN 4 stated she did not call Resident 1 ' s physician. During a concurrent interview and record review on 10/2/24 at 3:17 p.m. with LN 4, Resident 1 ' s clinical record titled, Order Summary Report was reviewed. Resident 1 ' s active physician order indicated, Suction orally PRN [as needed] for excessive secretions, as needed- order date 06/21/2023. LN 4 stated Resident 1 needed suction during his stay in the facility to maintain a patent airway because he was not able to swallow his secretions. During a concurrent interview and record review on 10/2/24 at 3:21p.m. with LN 4, Resident 1 ' s Treatment Administration Record for the months of July and August were reviewed. LN 4 confirmed there was no documentation Resident 1 was suctioned orally for oral secretions in the months of July and August. LN 4 verified she did not document suctioning Resident 1 on 8/26/24. There was no documented evidence Resident 1 was suctioned on 8/16/24, when he vomited prior to going to the hospital. During a concurrent interview and record review on 10/2/24 at 5:14 p.m. LN 3 stated she was the assigned nurse to care for Resident 1 on 8/26/24 for the evening shift. LN 3 stated Resident 1 ' s oxygen saturation (O2 Sat- a measurement of how much oxygen the blood is carrying as a percentage) dropped to the 80 ' s (a normal blood oxygen saturation level is between 95 % and 100%) even with oxygen on at 4 liters per minute (the rate of oxygen flow) with a nasal canula (a small plastic tube which fits into the nostrils for providing supplemental oxygen). LN 3 stated she texted the MD about Resident 1 ' s change in condition but the MD did not respond. LN 3 reviewed Resident 1 ' s clinical record and confirmed no vital signs were documented on 8/26/24 for the evening shift. LN 3 also stated when there was change in a resident ' s condition, vital signs should be checked more often to monitor the resident. A review of Resident 1's clinical record, Progress Note, dated 8/26/24, indicated, 1530 [3:30 p.m.] Received resident in stable condition, no s/s [signs and symptoms] of respiratory distress noted 1644 [4:44 p.m.] on 8/26/24, resident was unresponsive to verbal and tactile stimuli, heart and lung sounds are absent. During a review of Resident 1 ' s electronic clinical records titled, Weights and Vitals Summary, dated 8/26/24 indicated, Resident 1 ' s vital signs (Blood pressure, pulse, respirations, and temperature) readings were as follows: 8/26/24 at 5:37 a.m., Blood pressure 99/60, no pulse, no respirations, and no temperature were documented. 8/26/24 at 8:46 a.m., Blood Pressure 122/70, no pulse, no respirations, and no temperature were documented. 8/26/24 at 11:38 a.m., Blood Pressure 110/60, no pulse, no respirations, and no temperature were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555387 If continuation sheet Page 2 of 3 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 555387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Center 9107 N. Davis Road Stockton, CA 95209 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 0684 documented. Level of Harm - Minimal harm or potential for actual harm During a review of a facility document titled, STATION 1B VITALS, dated 8/26/24 indicated, Resident 1 ' s vital signs were not taken for the evening shift. Residents Affected - Few During an interview on 10/2/24 at 5:32 p.m. with the Director of Nursing (DON), the DON stated her expectation was that nurses should have assessed, reported, and documented when there was a change in Resident 1 ' s condition. The DON explained Resident 1 ' s condition changed when he vomited during the morning of 8/26/24, and the MD should have been notified. The DON stated the vital signs should have been taken more often, and further stated when Resident 1 ' s condition started worsening, Resident 1 should have been transferred to the acute care hospital for higher level of care. The DON stated Resident 1 ' s daughter was not called until after Resident 1 passed away. During a telephone interview on 10/4/24 at 3:40 p.m. with the MD, the MD stated Resident 1 should have been transferred to the acute care hospital when his condition started deteriorating for higher level of medical treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555387 If continuation sheet Page 3 of 3