Health inspection·January 30, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555470 If continuation sheet Page 2 of 6 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 555470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Creek Post-Acute 9289 Branstetter Place 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 - Actual harm Residents Affected - Few 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555470 If continuation sheet Page 3 of 6 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 555470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Creek Post-Acute 9289 Branstetter Place 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 - Actual harm Residents Affected - Few 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 00 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 assist with mobility/positioning when available 2 person assist with ADLs [activities of daily living, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom].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 observation on 1/28/26, at 3:15 p.m., in Resident 2's room, a gray fall mat was placed on the floor on the right side of Resident 2's bed.During a concurrent interview and record review on 1/29/26, at 3:32 p.m., with the Director of Nursing (DON), Resident 2's Electronic Medical Record (EMR) was reviewed. The DON stated that residents were assessed for the use of side rails (bed rails) during admission, as needed, and at the request of a resident and/or responsible party (RP, the person designated to direct the care of a loved one admitted into a nursing facility). The DON further stated that staff documented bed rail risk assessments in the residents' EMR, staff obtained consent from the resident and/or RP for the use of bed rails, staff explained the risks and benefits of bed rails to the residents and/or RPs, and staff documented bed rail use on the residents' care plans. The DON stated that if a resident's physician gave an order for bed rails, the nursing staff or the physical therapist did an assessment of the resident. The DON further stated that once the assessment was completed and the use of bed rails was deemed to be beneficial to the resident, the care plan was updated, and the maintenance staff installed the bed rails on the resident's bed immediately as soon as the staff did the assessment if the resident was a fall risk. The DON acknowledged that Resident 2 had a physician order for bed rails dated 1/26/26. The DON confirmed that a bed rail assessment was completed for Resident 2 on 1/26/26, and that Resident 2 consented to the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555470 If continuation sheet Page 4 of 6 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 555470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Creek Post-Acute 9289 Branstetter Place 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 - Actual harm Residents Affected - Few bed rails on 1/26/26. The DON further confirmed that Resident 2 was able to make her own healthcare decisions. The DON confirmed that the bed rails were installed on Resident 2's bed on 1/28/26 after obtaining consent from Resident 2's family member. The DON stated that the risk of delaying the installation of bed rails on Resident 2's bed was limited mobility or falling. The DON acknowledged that Resident 2's MDS Section GG-Functional Abilities Assessment, completed 9/22/25 indicated that Resident 2 needed substantial/maximal assistance with toileting/incontinence care. The DON stated that residents who needed substantial/maximal assistance with toileting/incontinence care required assistance of two CNAs if the resident needed to transfer from wheelchair to toilet, and only one CNA for incontinence care in bed unless the resident was dependent (staff did all the work and resident was unable to assist or move during care). The DON further stated that if a resident was at moderate to high risk for falls, care plan interventions for fall risk were individualized and documented on the care plan. The DON acknowledged that the IDT Falls Progress Note dated 1/25/26 indicated that a landing mat (fall mat) was implemented in Resident 2's room prior to the fall on 1/23/26. The DON confirmed that the fall mat was placed in Resident 2's room on 1/28/26 as an intervention after the fall on 1/23/26. The DON further confirmed the physician's order for a fall mat dated 1/29/26 in Resident 2's EMR. The DON acknowledged that once Resident 2 fell, the fall mat should have been placed immediately. The DON acknowledged that Resident 2's injury was preventable.During an interview on 1/29/26, at 4:06 p.m., with the Maintenance Director (MD), the MD stated that when a physician placed an order to install bed rails on a resident's bed, the staff notified Maintenance. The MD further stated that the facility had been low on bed rails. The MD stated that if the order for bed rails was for a resident at risk for falls, he borrowed the bed rails from a sister facility. The MD confirmed that the staff notified Maintenance of an order to place bed rails on Resident 2's bed on 1/26/26, so he reached out to a sister facility to get bed rails for Resident 2, and it took a day to get the bed rails. The MD further confirmed that the bed rails were installed on Resident 2's bed on 1/28/26. The MD stated that lots of residents requested bed rails for their beds and the facility did not have an issue with being low on supplies of bed rails.During a phone interview on 1/30/26, at 3:02 p.m., with Resident 2's treating physician at the facility (Physician 1), Physician 1 confirmed that he was Resident 2's treating physician at the facility. Physician 1 stated that he was not aware that only one CNA provided incontinent care to Resident 2 on the day when Resident 2 fell (1/23/26). Physician 1 further stated the facility CNAs needed training. Physician 1 stated that there should have been two CNAs providing incontinent care to Resident 2.A review of a facility P&P titled, Proper Use of Bed Rails, revised December 2016, indicated, .Purpose.The purpose of these guidelines are [sp] to ensure the safe use of bed rails as resident mobility aids.General Guidelines.2. Bed rails are only permissible if they are used.to assist with mobility and transfer of residents.3. An assessment will be made to determine.reason for using bed rails.9. Consent for bed rail use will be obtained from the resident.after presenting potential benefits and risks.A review of a facility P&P titled, Fall Risk Assessment, revised March 2018, indicated, .Policy Statement.The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and Implementation.1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.2. The nursing staff will ask the resident and/or his/her family about any history of the resident falling.7. The staff, with the support of the attending physician, will evaluate functional and psychological (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555470 If continuation sheet Page 5 of 6 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 555470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Creek Post-Acute 9289 Branstetter Place 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete factors that may increase fall risk, including.mobility.activities of daily living (ADL) capabilities.continence.9. The staff and attending physician will collaborate to identify and address modifiable risk factors and interventions.A review of the facility P&P titled, Safe Lifting and Movement of Residents, revised July 2017, indicated, .1. Resident safety, dignity, comfort and medical condition will be incorporated into decisions regarding the safe lifting and moving of residents . Event ID: Facility ID: 555470 If continuation sheet Page 6 of 6