Health inspection·February 26, 2026

CRYSTAL CREEK POST-ACUTE Code of Federal Regulations, Title 42, Section §483.25(d). Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 1/30/26, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate one complaint regarding resident care. The facility failed to ensure safety measures were in place while providing care for one of three sampled residents (Resident 2), when: 1. During a change of bedding, without securing Resident 2's right side of the bed, Certified Nursing Assistant (CNA) 2 turned Resident 2 to her right side, away from the CNA. This deficient practice resulted in Resident 2 falling out of bed and onto the floor on 1/23/26. Resident 2 sustained injuries including a fracture (broken bone) to her right elbow. 2. The staff did not implement interventions timely to prevent further falls and to reduce the impact of potential falls after Resident 2's fall incident on 1/23/26. This failure exposed Resident 2 to potential falls and associated injury. 1. A review of Resident 2's "ADMISSION RECORD," indicated that Resident 2 was admitted to the facility in 2025 with diagnoses which included intervertebral disc degeneration lumbar region (wear and tear of the discs in the lower back which compress nerves and cause pain), closed fracture right patella (broken kneecap), infection (presence of germs) of internal fixator right ankle (surgically reconnecting broken bones with screws, plates, rods, or nails), and unspecified fall (accidental fall where the exact nature of incident was not specified). A review of Resident 2's "Fall Risk Assessment," dated 10/18/25, indicated, "...Score: 25...Category: Moderate Risk for Falling..." A review of Resident 2's "SBAR (a communication tool for sharing information with teams and stands for Situation, Background, Assessment, and Recommendation or Requests) Nurse Progress Notes," dated 1/23/26, at 9:30 a.m., indicated, "...Fall Details...1. Describe the problem/symptom: Resident alert awake and verbally responsive CNA states "During care she [CNA 2] turned resident to the opposite side because she needs to change everything but before turn [sic] her [Resident 2] she said she make [sic] sure there should be enough space on the other side so she [Resident 2] would not fall so she turn [sic] her [Resident 2] and pulled the old flat sheet but according to her she held her [Resident 2] tooo [sic]. But when she let her [Resident 2] go to hold the curtain during care so that she can take out the old flat sheet but suddenly she [Resident 2] fell on the floor on her right side"...2. Was fall witnessed? Yes...3a. Location of fall: Resident Room...4. Date & Time of Fall: 01/23/2026 09:00 [9 a.m.]...5. What was the resident doing prior to the fall? Resident laid on her right side with [sic] holding curtain with both hands...6. Does the resident exhibit or complain of pain related to the fall? Yes...7. Location of pain: right elbow...8. Most recent pain level...Pain Level: 7...Date 01/23/2026 14:47 [2:47 p.m.]...Pain Scale...Numerical [a method of rating level of pain numerically with "0" meaning no pain and "10" meaning worst pain]...Body Observation...Location of injury...right humerus [arm] elbow...redness...Describe Range of Motion [ROM]...ROM painful/limited in upper extremity...Possible contributing factors...Orthopedic condition [a medical issue that affects the musculoskeletal system (consists of the body's bones, muscles, tendons, ligaments, joints, and cartilage)]...Muscle weakness...Date and time physician notified...01/23/2026 0900...Date and time Resident/Resident Representative notified...01/23/2026 1000 [10 a.m.]..." A review of Resident 2's "Transfer Record," dated 1/23/26, at 3:16 p.m., indicated that Resident 2 was transferred to an acute care facility's emergency department (ED) for treatment. A review of Resident 2's "Acute Care Emergency Room Treatment Record," dated 1/23/26, at 3:57 p.m., indicated, "...Chief Complaint...[Resident 2] from [facility] GLF [ground level fall] this AM [morning], positive right humerus fx [fracture] per x-ray done at facility...No LOC [loss of consciousness] No head strike [did not hit her head during fall]...Physical Exam...right upper arm and elbow TTP [tender to touch and palpation (a method of feeling with the fingers or hands during a physical examination)]...Diagnostic Results...XR [Xray] knee 3 view right [right knee x-ray] negative for fracture...XR Elbow 3+ Views Rt [x-ray of right elbow] horizontal distal humerus fracture without displacement [traumatic break in bone near the elbow where bones remain aligned]...CT head WO Con [Computerized Tomography of head without contrast, uses many x-rays to create pictures of the skull bones, brain and eye sockets without dye that could affect kidney function]...negative...long arm splint [support used to stabilize injury] to right arm...follow up in Ortho clinic in 1-3 days call to schedule...Plan: DC [discharge] back to facility...ice...elevation of right arm...pain medication as needed...keep splint in place until follow up appointment..." A review of Resident 2's "Nurse Progress Note," dated 1/24/26, at 2:06 a.m., indicated that Resident 2 was transferred back to the facility from the acute care ED. During a phone interview on 1/28/26, at 12:10 p.m., with Resident 2's Family Member (FM), the FM stated that on the morning of 1/23/26 she was at work and noticed a missed call from Resident 2. The FM further stated that she called Resident 2 back, and Resident 2 told her that earlier that morning during incontinence care (hygiene routine provided to individuals who cannot control their bladder or bowel movements), the CNA pulled the sheet, and she fell onto the garbage can near her bed then onto the floor. The FM stated that Resident 2 was sent to the ED later that day. The FM further stated that Resident 2 returned to the facility at 1 or 2 in the morning on 1/24/26. The FM stated that Resident 2 sustained a broken elbow from the fall. The FM further stated that Resident 2 said that she was in pain. The FM stated that Resident 2 was waiting to be scheduled for surgery. During a concurrent observation and interview on 1/28/26, at 2:15 p.m., with Resident 2 in her room, Resident 2 was noted to be resting in bed with her right arm in a splint and elevated on a pillow. Resident 2's bed was observed with side rails, was in low position with the wheel brakes locked. No fall mats were observed on the floor near Resident 2's bed. Resident 2 stated that she fell out of bed while a CNA provided care and her arm was broken as a result. Resident 2 further stated that the side rails were installed on her bed on 1/28/26. Resident 2 stated that she had pain, but staff gave pain medication that provided relief to her arm. During an interview on 1/28/26, at 2:32 p.m., with CNA 2, CNA 2 stated that she knew Resident 2. CNA 2 confirmed that she was the CNA providing care to Resident 2 when Resident 2 fell on 1/23/26. CNA 2 stated that she checked Resident 2 that morning, and Resident 2 was incontinent of stool (had an uncontrolled bowel movement in the bed). CNA 2 further stated that she changed the bed linens and rolled the soiled bed linens to tuck them under Resident 2. CNA 2 stated that she had one hand on Resident 2 to steady her and one hand on the tucked linen. CNA 2 further stated that she pulled the tucked linens with one hand and attempted to remove them from the bed, but she could not remove them with one hand. CNA 2 stated that she told Resident 2 to hold onto the cabinet near the bed or the bed frame so that she could pull the soiled linens off the bed with both hands. CNA 2 further stated that she did not know that Resident 2 held the privacy curtain. CNA 2 stated that she let Resident 2 know that she was about to remove the hand she used to support her so that she could use both hands to pull the soiled linen off the bed. CNA 2 further stated that Resident 2 said that it was okay, so she let go of Resident 2 and used both hands to pull the soiled linen off the bed. CNA 2 stated that Resident 2 fell off the bed when she pulled the soiled linen off the bed and landed on the floor on her right side. CNA 2 further stated that she went to tell the charge nurse what happened quickly. CNA 2 stated that her coworkers came to the room and helped her to get Resident 2 off the floor and back into bed. CNA 2 stated that Resident 2 complained that her right elbow hurt. CNA 2 further stated that she used folded blankets to support Resident 2's right arm and support her on her left side. CNA 2 further stated that the charge nurse and the supervisor came to the room to assist. CNA 2 stated that the charge nurse called Resident 2's family. CNA 2 acknowledged that Resident 2 did not have side rails on her bed or fall mats on the floor on either side of the bed at the time of the fall. CNA 2 confirmed that side rails were installed on Resident 2's bed on 1/28/26. During an interview on 1/28/26, at 2:38 p.m., with Licensed Nurse (LN) 1, LN 1 stated that he was on duty the day when Resident 2 fell (1/23/26). LN 1 further stated that Resident 2's family and physician were called. LN 1 stated that the physician ordered a stat (immediately, as soon as possible) x-ray for Resident 2's right arm. LN 1 further stated that the facility physicians highly encouraged the LNs to get the stat x-ray first before making a decision to send residents out to the emergency department (ED) for care. LN 1 stated that the x-ray results were reported to Resident 2's physician at 1:30 p.m., on 1/23/26, Norco (medication prescribed for pain) was given to Resident 2 for pain, and Resident 2 was sent to the ED per the physician's orders. During an interview on 1/28/26, at 3:16 p.m., with LN 2, LN 2 stated that she knew Resident 2. LN 2 further stated that she was the charge nurse on duty when Resident 2 fell out of bed and broke her arm (on 1/23/26). LN 2 stated that she was giving medications to a resident when CNA 2 provided incontinent care to Resident 2. LN 2 further stated that she heard a noise and went to Resident 2's room. LN 2 stated that Resident 2 was lying on the floor on her right side. LN 2 further stated that she notified the supervisor. LN 2 stated that the staff moved Resident 2 back to bed. LN 2 further stated that she did a head-to-toe assessment on Resident 2 and took vital signs (temperature, heart rate, and blood pressure). LN 2 stated that Resident 2 complained of pain in her right arm with movement. LN 2 further stated that she notified the physician and the physician ordered an x-ray stat. LN 2 stated that she gave Resident 2 medication for the pain. LN 2 further stated that the x-ray was completed at around 10 a.m. that day. LN 2 stated that after the x-ray results were phoned in to the physician, Resident 2 was sent to the ED. LN 2 stated that the bed rails were installed on the bed after consent was obtained from Resident 2's family, but she was not sure when the bed rails were installed. LN 2 stated that Resident 2 required maximum assistance with incontinence care. LN 2 confirmed that only one CNA assisted Resident 2 with incontinence care that day. LN 2 further stated that residents who required maximum assistance required two CNAs to assist with care. During an interview on 1/28/26, at 3:20 p.m., with CNA 2, CNA 2 stated that Resident 2 was able to move in bed, so only one CNA was needed for incontinent care. During a concurrent interview and record review on 1/29/26, at 2:10 p.m., with the MDS Coordinator (MDS Coordinator [MDS], a nurse that collects data related to residents in order to develop and evaluate a comprehensive care plan and to make sure the facility gets payment from Medicare and Medicaid), Resident 2's "MDS (Minimum Data Set, a comprehensive care assessment tool) Section GG-Functional Abilities Assessment," dated 9/22/25 was reviewed. The MDS confirmed that Resident 2's "MDS Section GG-Functional Abilities Assessment," indicated that Resident 2 needed substantial/maximum assistance (Helper does more than half the effort. Helper holds or lifts trunk [body] and limbs and provides more than half the effort) with toileting/hygiene. The MDS stated that the CNAs did most of the work for residents that needed maximum assistance with toileting/hygiene. The MDS stated that if a resident was incontinent, one CNA could provide the care. 2. A review of Resident 2's "Physician Order Summary," indicated, "...Resident is capable of making his/her own health decisions...Active...Order Date...01/08/2026..." A review of Resident 2's "Physician Order Summary," indicated, "...May have quarter siderails in bed for mobility and positioning (start when available)...Active...Order Date...01/26/2026..." A review of Resident 2's "Physician Order Summary," indicated, "...Apply landing mat on floor to reduce impact and injury of fall while in bed. Check placement QS [every shift]. every shift...Active...Order Date...01/29/2026...Start Date...01/29/2026..." During a review of Resident 2's "Interdisciplinary Team Falls Progress Notes (IDT, a team of professional staff or a care team consisting of different disciplines working together towards the goal of the residents)," dated 1/25/26, 5:07 p.m., the "IDT Falls Progress Notes," indicated, "...Summary and Root Cause Analysis...Resident fell when [CNA 2] was turning her. Per resident statement, she was holding on to the side of the mattress while CNA was doing the care. She was leaning too much resulting to loss of balance and fell...PREDISPOSING/RISK FACTORS FOR FALLS...BIMS score 15 [Brief Interview for Mental Status- a tool to assess cognition (the mental processes involved in gaining knowledge and understanding). The total possible BIMS score ranges from 0 to 15. 13 - 15: cognitively intact; 08 - 12: moderately impaired; 00 - 07: severe impairment]...History of Falls...Muscle Weakness...Gait/Balance Deficit...Poor Safety Awareness...Overestimates limits...Other predisposing risk factors...h/o [history of] falls prior to admission...PREVENTIVE MEASURE/S PRIOR TO FALL...ASSESSED FOR NEEDS: TOILETING, REPOSITIONING, FLUIDS, OR SNACK Q [every] 2 HOURS...BED IN LOW POSITION WHEN IN BED TO LESSEN IMPACT OF FALLS...KEPT BED LOCKED...LANDING MAT ON FLOOR TO REDUCE IMPACT AND INJURY OF FALL...NOTES...Interventions...pain management Xray right arm low bed landing mat frequent visual check sent to ER [emergency department] for further eval d/t [due to] Xray result of right humerus [long bone of upper arm extending from shoulder to elbow] f/u [follow up] with Ortho IDT Recommendations: Quarter side rail to bed to a