Health inspection·February 12, 2025

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician ' s order. Residents Affected - Few This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1. Findings: During a review of Resident 1's admission record, the facility admitted Resident 1 on 12/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), and dysphagia (difficulty swallowing). During a review of Resident 1 ' s physician orders dated 12/30/2024 at 5:15 pm, indicated, DROPLET (prevent the spread of infections that are spread through the air by coughing, sneezing, or talking. Precautions include wearing a mask, washing hands, and limiting movement outside of a patient's room) AND CONTACT ISOLATION (used when there is a risk of transmission through direct or indirect contact with a patient or their environment) + EYE PROTECTION. During a review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/8/2025 at 6:2 pm, indicated that on 1/8/2025, Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) identified labored or rapid breathing and shortness of breath. The SBAR indicated, Notified by CN (Charge Nurse) that patient oxygen level is 88% (normal range between 92-100%) and that his BP (Blood Pressure) is low. Assessed res. (Resident 1), put him on 5L (Liters) via 02 (oxygen) mask but unsuccessful to raise 02, placed on high flow oxygen15L via nonrebreather mask (a medical device that delivers oxygen to patients who need more than they can get on their own), but res having labored breathing with respiration rate 40/min. Res. visibly making noises while struggling to inhale/exhale, recent flu (Influenza) dx (diagnosis) and completed ATB (antibiotic therapy), with breathing treatment PRN (as needed) unsuccessful to raise 02 via previous COC. 911 (an emergency number to get immediate help from police, fire department, or ambulance) called d/t (due to) high respiratory rate, hypoxic (a condition where there is an insufficient amount of oxygen in the body's tissues or blood) and diff. (difficulty) breathing. Page 1 of 4 055161 055161 02/12/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/21/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was required supervision or touching assistance for eating and required between substantial/maximal assistance and dependence for all other Activities of Daily Living such as: (ADLs- routine tasks/activities such as, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of Resident 1's history and physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 1/23/2025 indicated Resident 1 had the capacity to make decisions. During an interview with the Infection Prevention Nurse (IPN) on 2/11/2025 at 2:20 pm, the IPN stated that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Influenza A (commonly known as the flu, is a contagious respiratory illness caused by influenza viruses) and was sent to General Acute Care Hospital (GACH) on 1/8/2025. On 1/17/2025 when Resident 1 was readmitted to the facility with no orders for isolation and that Resident 1 had tested negative to Influenza A while at GACH. IPN admitted that residents in isolation had to have an active physician ' s order. IPN stated that the potential effects of placing a resident in isolation could result in resident being isolated from other residents and may lead to feelings of anxiety. During an interview with the Licensed Vocational Nurse (LVN) 1 on 2/11/2025 at 4 pm, LVN 1 admitted that Resident 1 was in isolation upon readmission from GACH on 1/17/2025 even though there was no active order. LVN 1 stated that residents should never be placed on isolation without physician ' s orders. LVN 1 stated the potential effects of isolating a resident without orders may lead to depression. During a concurrent interview and record review of Resident 1 ' s orders with the Director of Nursing (DON) on 2/11/25 at 4:19 pm, the DON confirmed that there was no active order for isolation when Resident 1 was readmitted on [DATE]. The DON was unable to state the potential effects of placing a resident in isolation without an order. During an interview with the Medical Doctor (MD) 1on 2/25/2025 at 2:47 pm, MD 1 stated residents diagnosed with influenza typically stay in isolation for 5 days especially when they are receiving treatment. He stated that Resident 1 should not have been in isolation. During a review of the facility's policy and procedures (P&P) titled Isolation - Categories of Transmission-Based Precautions, revised 1/2025, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The same P&P indicated The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 1/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to 055161 Page 2 of 4 055161 02/12/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Based on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician's order. This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1. Findings: During a review of Resident 1's admission record, the facility admitted Resident 1 on 12/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), and dysphagia (difficulty swallowing). During a review of Resident 1's physician orders dated 12/30/2024 at 5:15 pm, indicated, DROPLET (prevent the spread of infections that are spread through the air by coughing, sneezing, or talking. Precautions include wearing a mask, washing hands, and limiting movement outside of a patient's room) AND CONTACT ISOLATION (used when there is a risk of transmission through direct or indirect contact with a patient or their environment) + EYE PROTECTION. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/8/2025 at 6:2 pm, indicated that on 1/8/2025, Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) identified labored or rapid breathing and shortness of breath. The SBAR indicated, Notified by CN (Charge Nurse) that patient oxygen level is 88% (normal range between 92-100%) and that his BP (Blood Pressure) is low. Assessed res. (Resident 1), put him on 5L (Liters) via 02 (oxygen) mask but unsuccessful to raise 02, placed on high flow oxygen15L via nonrebreather mask (a medical device that delivers oxygen to patients who need more than they can get on their own), but res having labored breathing with respiration rate 40/min. Res. visibly making noises while struggling to inhale/exhale, recent flu (Influenza) dx (diagnosis) and completed ATB (antibiotic therapy), with breathing treatment PRN (as needed) unsuccessful to raise 02 via previous COC. 911 (an emergency number to get immediate help from police, fire department, or ambulance) called d/t (due to) high respiratory rate, hypoxic (a condition where there is an insufficient amount of oxygen in the body's tissues or blood) and diff. (difficulty) breathing. During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 1/21/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was required supervision or touching assistance for eating and required between substantial/maximal assistance and dependence for all other Activities of Daily Living such as: (ADLs- routine tasks/activities such as, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of Resident 1's history and physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, 055161 Page 3 of 4 055161 02/12/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few performs a physical examination, and then documents their findings) dated 1/23/2025 indicated Resident 1 had the capacity to make decisions. During an interview with the Infection Prevention Nurse (IPN) on 2/11/2025 at 2:20 pm, the IPN stated that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Influenza A (commonly known as the flu, is a contagious respiratory illness caused by influenza viruses) and was sent to General Acute Care Hospital (GACH) on 1/8/2025. On 1/17/2025 when Resident 1 was readmitted to the facility with no orders for isolation and that Resident 1 had tested negative to Influenza A while at GACH. IPN admitted that residents in isolation had to have an active physician's order. IPN stated that the potential effects of placing a resident in isolation could result in resident being isolated from other residents and may lead to feelings of anxiety. During an interview with the Licensed Vocational Nurse (LVN) 1 on 2/11/2025 at 4 pm, LVN 1 admitted that Resident 1 was in isolation upon readmission from GACH on 1/17/2025 even though there was no active order. LVN 1 stated that residents should never be placed on isolation without physician's orders. LVN 1 stated the potential effects of isolating a resident without orders may lead to depression. During a concurrent interview and record review of Resident 1's orders with the Director of Nursing (DON) on 2/11/25 at 4:19 pm, the DON confirmed that there was no active order for isolation when Resident 1 was readmitted on [DATE]. The DON was unable to state the potential effects of placing a resident in isolation without an order. During an interview with the Medical Doctor (MD) 1on 2/25/2025 at 2:47 pm, MD 1 stated residents diagnosed with influenza typically stay in isolation for 5 days especially when they are receiving treatment. He stated that Resident 1 should not have been in isolation. During a review of the facility's policy and procedures (P&P) titled Isolation - Categories of Transmission-Based Precautions, revised 1/2025, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The same P&P indicated The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 1/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 055161 Page 4 of 4