Health inspection·May 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, and record review, the facility failed to provide an environment to ensure residents' needs related to nursing services were met for a census of 72 when only one scheduled nurse worked the entire night shift on 5/4/25. This failure had the potential for residents' care services not being met by nursing staff and could affect the health and well-being of all residents in the facility. Findings: During an interview on 5/8/25, at 2:58 p.m., Licensed Nurse (LN) 1 stated that in emergency situations such as a code blue (a medical emergency requiring urgent medical help) a nursing shortage could lead to placing residents' safety and well-being at risk. During a phone interview on 5/8/25, at 3:54 p.m., LN 2 confirmed there was one nurse for the entire night shift on 5/4/25. LN 2 stated that it was not a safe practice to have one nurse for the entire facility if a resident had a medical emergency. LN 2 further stated that this unsafe practice could possibly affect residents' safety. During an interview on 5/9/25, at 6:15 a.m., Certified Nursing Assistant (CNA) 1 stated there was a possibility of placing all residents' safety at risk when there was one licensed nurse working on the floor for the whole night shift. CNA 1 further stated medical emergencies could happen anytime during the shift and it would be difficult for one licensed nurse to handle the emergency. During an interview on 5/9/25, at 6:32 a.m., CNA 2 stated shortages in nursing would impact residents' health and safety. CNA 2 further stated there was a possibility for residents to not to receive medications as they were scheduled by the physician which could lead to a decline in health and suffer in emergency situations. During a concurrent interview and record review on 5/9/25, at 9:35 a.m., with the Staffing Coordinator (SC), the facility document titled, [facility name] DAILY STAFFING, dated 5/4/25 was reviewed. The SC confirmed that on 5/4/25, during the 10:30 p.m.-7 a.m. night shift, only one LN worked for the entire shift, and the second LN clocked out at 12:25 a.m. on 5/4/25. The SC further stated that one of the nurses tried calling staff to fill in the shortage. During a concurrent interview and record review on 5/9/25, at 10:52 a.m., with the Director of Nursing (DON) the facility document titled, [facility name] Daily Census, and [facility name] DAILY STAFFING, dated 5/4/25 were reviewed. The DON confirmed that they were short of one licensed nurse from Page 1 of 2 555387 555387 05/09/2025 Creekside Center 9107 N. Davis Road Stockton, CA 95209

F 0689 Level of Harm - Minimal harm or potential for actual harm 12:25 a.m.-7 a.m. for a census of 72 and stated that it might result in placing a census of 72 at risk for not receiving medications in a timely manner, increased risk for falls, and unable to meet resident needs in a medical emergency that would affect residents' safety and well-being. The DON further stated her expectation from the licensed staff was to leave a voicemail message when a licensed nurse called her on 5/4/25 at 11:32 p.m. The DON stated her expectation was not met by the licensed staff. Residents Affected - Few A review of an undated facility provided document titled, Facility Assessment Tool, indicated, .Guidelines for Conducting the Assessment .4. The Facility Assessment will be used to .c. Consider the specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to the resident population .3. Facility resources .staffing plan 3.2. Based on the facility's resident population and their needs for care and support, describe the facility's general approach to staffing to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents, as identified through resident assessments and care plans at any given time . A review of the facility provided job description titled, Director of Nursing, revised on October 2020, indicated, .The primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times .Duties and Responsibilities .Provide direct nursing care and resident assessments .Ensure the facility has sufficient nursing staff .Working Conditions .Works beyond normal working hours and on weekends and holidays when necessary . 555387 Page 2 of 2