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
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555387
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
05/09/2025
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 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
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555387
If continuation sheet
Page 2 of 2
