Crystal Creek Post-acute

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Concern, indicated, Please see Attached Statement . The attached statement indicated the following, On 7/30/2025 around 3:30pm notified by DON on [Resident 1] stating to [FM 1] that someone had hit her on her head, Statement was made to SSA [Social Services Assistant] and DON. SSA used translation services, but [Resident 1] unable to answer the questions, SSD called [FM 1] to follow up on statement, Per [FM 1] she stated [Resident 1] expressed a lady with black hair, medium build, light in color hit her on the head. SSD explained to [FM 1] that facility will follow up with investigation. [FM 1] said she knows [Resident 1's] mind is not sharp, and she has moments of forgetfulness .DON and SSA called language line (Cantonese) to communicate with [Resident 1]. DON asked [Resident 1] several question [sic] regarding abuse allegations, language line person was unable to understand [Resident 1]. DON and ssa [sic] then called [FM 1], [FM 1] let [NAME] [sic] and ssa [sic] know that she would need to visibly see [Resident 1] that is how she is able to understand [Resident 1] and is able to communicate better. DON and SSA video called [Resident 1's FM 1]. [FM 1] asked [Resident 1] what happened, [Resident 1] pointed to her head and according to [FM 1] who was translating for DON and SSA, [FM 1] stated that [Resident 1] said that someone hit her. [FM 1] translated that [Resident 1] stated that someone came in her room and hit her on

the head and left out of the room.A record review of Resident 1's clinical record did not indicate any progress notes (a record of patient condition and care received), care plans (outlines a patient's health conditions, treatment and support required to achieve health goals), and social services notes regarding Resident 1's allegations of abuse.A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/21, the policy indicated, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies . and thoroughly investigated by facility management. Findings of all investigations are documented and reported . If resident abuse . is suspected,

the suspicion must be reported immediately to the administrator and to other officials according to state law . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies . The state licensing/certification agency responsible for surveying/licensing

the facility . 'Immediately' is defined as within two hours of an allegation involving abuse or result in serious bodily injury . within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .

Event ID:

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by a staff person while care was being provided to Resident 1, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility.This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) of her right dominant side.A review of Resident 1's clinical document titled, GRIEVANCE / COMPLAINT RESOLUTION REPORT, dated 7/30/25, indicated, .Specific Date of Alleged Occurrence: 07/30/2025. In the section titled Investigative Actions/Pertinent Findings, did not indicate that other residents were interviewed during the facility's investigation of Resident 1's alleged abuse.During an interview with the Director of Nursing (DON) on 9/23/25, at 4:14 p.m., the DON confirmed no other residents were interviewed regarding Resident 1's allegations of abuse.During an

interview with Social Services Director (SSD) 2 on 9/26/25, at 11:22 a.m., SSD 2 stated she did not know why other residents were not interviewed. SSD 2 explained it was part of the investigation process for alleged abuse that other residents were interviewed. A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/21, the policy indicated, . All allegations are thoroughly investigated . The individual conducting the investigation as a minimum . interviews the resident's roommate, family member, and visitors . interviews other residents to whom the accused employee provides care or services .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet