Complaint Investigation

Crystal Creek Post-acute

January 30, 2026 · Stockton, CA · 9289 Branstetter Place

Citations 1

CMS Rating 2/5

Beds 152

Provider ID 555470

Healthcare Facility

Crystal Creek Post-acute

Stockton, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

CRYSTAL CREEK POST-ACUTE in STOCKTON, CA — inspection on January 30, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689

Quality of Life and Care Deficiencies

DON acknowledged that Resident 2's injury was preventable.

During an interview on 1/29/26, at 4:06

install bed rails on a resident's bed, the staff notified Maintenance.

The MD further stated that the

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 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 .

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STOCKTON, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CRYSTAL CREEK POST-ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.