Health inspection·March 6, 2025

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 Based on interview and record review, the facility failed to ensure adequate treatment and services were provided for one of three sampled residents (Resident 1) when, Resident 1 was not transferred to an acute care hospital (provides short-term treatment for illnesses, injuries, or surgeries that require immediate medical attention) in a timely manner for further evaluation after Resident 1 had an unwitnessed fall with a head injury on 2/17/25 and Resident 1 had a fall again on 2/28/25 with noted pain to Resident 1 ' s left hip. Residents Affected - Few This failure placed Resident 1 at risk for delayed treatment and services that could possibly result in a decline in health and well-being. Findings: On 2/24/25, the Department received a complaint report that Resident 1 was not transferred after a fall on 2/17/25 to the acute care hospital for further evaluation till the following day. On 3/4/25, the Department received an additional complaint report that Resident 1 was not transferred after a fall on 2/28/25 to the acute care hospital for further evaluation until the following day. Review of Resident 1 ' s admission RECORD, indicated Resident 1 was admitted to the facility in early 2025 with diagnoses which included dementia (a decline in memory or other thinking skills severed enough to reduce a person ' s ability to perform everyday activities), difficulty in walking, muscle weakness, and repeated falls. Review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool), dated 1/25/25, the cognitive patterns section of the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) Summary Score of 3 out of 15 indicating a severely impaired mental functioning (a significant decline in cognitive abilities that substantially interferes with daily life and activities). Review of Resident 1 ' s HISTORY AND PHYSICAL EXAMINATION, dated 1/25/25, indicated Resident 1 had fluctuating capacity to understand and make decisions due to cognitive impairment. A. Review of Resident 1 ' s eInteract SBAR [Situation Background Assessment Recommendation; verbal or written communication tool that helps provide essential, concise information] Summary, dated 2/17/25, indicated Resident 1 had a fall on 2/17/25 at 3:30 a.m. This summary also revealed Resident 1 had indicated she hit her head and a small hematoma (bruise or swelling caused by bleeding under the skin or into a tissue) was noted to the right posterior lobe (back area of the brain) of the head and she was in pain. Review of Resident 1 ' s Fall Care Plan, dated 2/17/25, indicated, .The resident has had an actual Page 1 of 3 555387 555387 03/06/2025 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0684 fall with hematoma to back of head . Level of Harm - Minimal harm or potential for actual harm Review of Resident 1 ' s eInteract SBAR Summary, dated 2/18/25, at 8:35 a.m., indicated, .Resident noted to have two episodes of nausea with vomiting. S/p [status post] unwitnessed fall resulting in head injury on 2/17. Resident now present with increased confusion and unable to tell what time of the day it is, her age, and states she does not remember yesterday which is abnormal from baseline . Residents Affected - Few Review of Resident 1 ' s Progress Note, dated 2/18/25, at 9:56 a.m., indicated, .resident was sent out to the hospital for further evaluation . During an interview on 3/6/25, at 10:19 a.m. with Licensed Nurse (LN) 1, LN 1 stated she would call the attending physician and would request to send the resident to the acute care hospital for further evaluation when a head injury was involved, and it was an unwitnessed fall. LN 1 also stated the resident would be better assessed when transferred to the acute care hospital. During a phone interview on 3/27/25, at 2:55 p.m. with LN 2, LN 2 stated she would also notify the Director of Nursing (DON) for a fall involving a head injury for further instructions especially if the attending physician did not respond immediately. Further review of Resident 1 ' s eInteract SBAR Summary, dated 2/17/25, there was no documented evidence the DON was notified immediately after the fall. During an interview on 3/6/25, at 12:45 p.m. with the DON, the DON stated she would have expected to be called regarding an unwitnessed fall with a head injury to ensure proper implementation of interventions. B. Review of Resident 1 ' s eInteract SBAR Summary, dated 2/28/25, indicated Resident 1 had a fall on 2/28/25, at 11:49 p.m. Resident 1 ' s SBAR summary also indicated, .legs bent and soles of feet on the floor .Nodule noted to left hip . This summary also revealed Resident 1 was in pain. Review of Resident 1 ' s eInteract Change in Condition Evaluation, dated 2/28/25, under section Functional Status Evaluation indicated, .Is the fall: 1. Associated with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere [was marked] . Under the section Provider Notification and Feedback indicated, .2. Date and time of clinician notification: 3/1/25 [at] 6 a.m . Under the section Pain Status Evaluation indicated, .7a. Does the resident/patient have pain? 1. Yes [was marked] .Describe musculoskeletal pain: 1. Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall [was marked] .7e. Specify exact location of pain .Left trochanter (hip) .Small nodule noted with pain to touch . Under section Resident Representative Notification, indicated, .2. Date and time of family/resident representative notification: 3/1/25 [at] 6:07 a.m . Review of Resident 1 ' s Nurses Progress Note, dated 3/1/25 at 8:10 a.m., indicated, .he [family member] preferred her [Resident 1] be sent out [transfer to acute hospital] for further evaluation and treatment . Review of Resident 1 ' s eInteract Transfer Form, dated 3/1/25, at 2:12 p.m., indicated Resident 1 was transferred to the acute care hospital. Review of Resident 1 ' s General Progress Note, dated 3/1/25, at 6:25 p.m., indicated, .pt 555387 Page 2 of 3 555387 03/06/2025 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0684 [patient/Resident 1] admitted .due to sustaining a left hip fracture . Level of Harm - Minimal harm or potential for actual harm Review of Resident 1 ' s Interdisciplinary Care Conference, dated 3/3/25, indicated, .Concern/Issue: Fall with major injury significant event occurring on 3/1/25 regarding the resident where she had sustained a fall on the night of 2.28.2025, resulting in the transfer and admission to the acute [care hospital] with a left hip fracture . Residents Affected - Few Review of Resident 1 ' s Discharge Summary from the acute care hospital, dated 3/1/25, indicated, .Left greater trochanter fracture and inferior pubic ramus fracture [broken bone to left hip and lower part of the pelvis] . During an interview on 3/6/25, at 10:53 a.m. with the Primary Care Physician (PCP), the PCP stated he knew about the Resident 1 ' s fall and had ordered for an x-ray based on the reported assessment and information received from the facility nurse. The PCP further stated family had requested to transfer Resident 1 to the acute care hospital and had the x-ray done at the hospital. The PCP explained if a resident ' s fall did not involve a head injury, was not on any blood thinner, and could move all extremities, he would order an x-ray. The PCP stated had he would have known the resident to have signs of fracture, he would had ordered to transfer the resident to the acute care hospital. The PCP further explained he did not receive a report from the facility nurse regarding Resident 1 ' s signs of a fracture. During an interview on 3/6/25, at 12:45 p.m., with the DON, the DON stated she would have expected to be called of an unwitnessed fall with an injury or with pain involved to ensure proper implementation of care and services to prevent any delay in treatment. The DON confirmed she was not notified of the fall till the next morning. During an interview on 3/27/25, at 2:55 p.m. with LN 2, LN 2 stated she assessed Resident 1 and stated Resident 1 had indicated she had soreness to left hip. LN 2 further stated there was also some bruising to Resident 1 ' s left hip. LN 2 explained she had monitored Resident 1 during her night shift but did not fully check on Resident 1 ' s leg. Review of the facility ' s Clinical Protocol titled, Acute Condition Changes, revised 3/18, indicated, .Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who collected and organized pertinent information, including the resident/patient ' s current symptoms and status .The nursing staff will contact the physician based on the urgency of the situation .The attending physician .will respond in a timely manner to notification of problems or changes in condition and status .The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response . 555387 Page 3 of 3