Other·February 4, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00664605 Representing the Department of Public Health: Health Facilities Evaluator Nurse, 29825 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F600 SS=E Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility documents, the facility failed to protect two of three sampled residents (Resident 2 and Resident 3) from sexual abuse. This failure placed Resident 2 and Resident 3 at risk for decline in psychosocial well-being. Findings: Resident 1 was admitted to the facility in 2016 with diagnoses which included a traumatic brain injury, bipolar disorder (widely swinging moods), and psychosis (false beliefs and seeing or hearing something that is not there). His Minimum Data Set (MDS, an assessment tool), dated 9/11/19, indicated he had moderate memory impairment and required supervision with his activities of daily living (ADLs). Review of Resident 1's psychiatric progress note, dated 6/13/19, indicated, "Dementia [a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities] Depression Agitation improved...Discontinue [name brand of antipsychotic, medications used to reduce or relieve symptoms of psychosis]." Review of Resident 1's care plan, initiated on 4/1/16 and revised on 9/12/19, indicated, "The resident has impaired cognitive function/dementia of impaired thought processes r/t [related to] Unspecified Dementia m/b [manifested by] short & long term memory loss, impaired decision making ability" One of the interventions for this care plan included, "Cue, reorient and supervise as needed." Review of Resident 1's care plan, initiated on 7/5/16 and revised on 9/12/19 indicated, "The resident has a mood/behavior problem m/b [manifested by] verbal and physical aggression FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE r/t [related to] Dx [diagnosis] of Unsp. [unspecified] Dementia, Bipolar Disorder [a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks], and Unsp. Psychosis [characterized as disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what isn't]" One of the interventions of this care plan included, "Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc)..." Review of Resident 1's physician progress note, dated 10/1/19, indicated, "Dementia with behavior problems..." Review of Resident 1's care plan, initiated on 11/21/19 and revised on 11/22/19, indicated, "The resident exhibits sexually inappropriate behavioral symptoms: Sexually inappropriate behavior towards female peer 10/29/19 Sexual behavior towards female peer on 11/21/19." One of the interventions of this care plan included, "Intervene and redirect when inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses and behavior (Social Skills). Remind the resident to refrain from...inappropriate touching..." Review of Resident 1's care plan, initiated on 11/21/19, indicated, "Resident witnessed with sexually inappropriate behavior by grabbing female resident breasts (10/29) Resident witnessed with sexually inappropriate behavior by exposing himself and taking female resident hands to his genitals(11/21) [sic]. The Interventions/Tasks included, "MD notified...Notified State Dept...Psyche evaluation..." Review of Resident 1's Social Services note, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 11/22/19, indicated, "When asked if resident recalled the incident [11/21/19], resident admitted taking female peer's hand and touching his genitals. When ask (sic) why, resident stated: 'I just wanted to feel something on my penis'..." Resident 2 was admitted to the facility in 2015 with diagnoses which included severe memory impairment. Review of Resident 2's most recent MDS, dated 10/8/19, indicated she had severe memory impairment and required extensive assistance with most ADLs. Review of Resident 2's "...Alleged Abuse Report of Incident...," dated 11/21/19, indicated, "CNA [Certified Nurses Assistant] reported to charge nurse that [Resident 1] had his pants down and exposed himself to a female [Resident 2] grabbed her hand and move (sic) her hand toward his genitals...Social Services Note...When asked if [Resident 2] recalled the incident, resident stated "penis". When asked if she is feeling fearful or anxious, Resident nodded 'yes'..." Resident 3 was admitted to the facility in 2017 with diagnoses which included dementia. Review of Resident 3's most recent MDS, dated 8/27/19, indicated she had severe memory impairment and required extensive to total assistance with all ADLs. Review of Resident 3's "...Alleged Abuse Report of Incident...," dated 10/29/19, indicated, "Staff member reported that another resident [Resident 1] had his hand placed on resident's breast, moving in a circular motion, and proceeded to touch other breast in the same motion..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with CNA 1 on 11/22/19, at 1:51 p.m., she was asked about Resident 1 and said, "I've seen him push another [female] resident into his room and I asked him what he was doing. He said she wanted to go into his room. I told him "I don't think so" so I removed her. I told the nurse. I'm not sure if she told anyone but I charted it. It was a couple months ago. No one has inserviced us in [Resident 1's] behaviors...When I work with him, he'll try to look down my blouse..." During an interview with the Director of Staff Development (DSD) on 11/22/19, at 2:25 p.m., he said, "I heard the report this morning...They were saying there have been issues in the past [with Resident 1]..." During an interview with the Assistant DSD [ADSD] on 11/22/19 at 2:32 p.m., she said, "I wasn't made aware of any incident with [Resident 1]..." Resident 4 was admitted to the facility in 2016 with diagnoses which included a communication deficit and encephalopathy (a brain disease). Review of her most recent MDS, dated 10/8/19, indicated she was alert and oriented and was mostly independent with her ADLs. During an interview with Resident 4 on 11/22/19, at 3:10 p.m., she said, "He [Resident 1] used to bother me a few months ago...I saw him going into the next room and told him to get out. I keep my eye on him..." During an interview with CNA 3 on 11/22/19, at 3:15 p.m. she was asked about the incident between Resident 1 and Resident 2. CNA 3 said, "I saw him [Resident 1] with his [sweat] pants down. He was holding the pants down FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with his right hand, holding her [Resident 2's] left hand with his left hand and rubbing his penis up and down with her hand...He knew what he was doing...I heard there was another incident with him." During an interview with Licensed Nurse 2 (LN 2) on 11/22/19, at 3:30 p.m., she said, "This was the second incident. He [Resident 1] grabbed another [female] resident's breast about 10/29/19..." A request was made on 11/25/19, for the incident charted by CNA 1 and the name of the licensed nurse she informed; the requested information was not provided. During an interview with the Director of Nurses (DON) on 12/16/19, at 10:05 a.m., she was asked what her expectations were regarding sexual abuse and said, "Staff should do their best to prevent sexual abuse. It's not OK. If we are aware of this behavior in the past, staff should do their utmost to prevent another incident." Review of the facility document titled, "ABUSE PREVENTION, INTERVENTION, INVESTIGATION & CRIME REPORTING POLICY," revised 2016, indicated, "The resident has the right to be free from abuse...The facility is responsible for assuring resident safety by prohibiting...sexual, or physical abuse...Abuse is the willful infliction of...intimidation...with resulting...mental anguish...It includes...sexual abuse...Sexual abuse is non-consensual contact of any type with a resident..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QVXD11 Facility ID: CA030000814 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555470 (X3) DATE SURVEY COMPLETED 01/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRYSTAL CREEK POST-ACUTE 9289 Branstetter Place Stockton, CA 95209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: QVXD11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000814 (X5) COMPLETE DATE If continuation sheet 7 of 7