Health inspection·May 16, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the policy and procedures for discharge planning were followed for one of three sampled residents (Resident 1). This failure resulted in the resident not being properly informed and involved in their discharge plan. Findings: During a review of Resident 1 ' s admission Record dated 5/16/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including; diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (HTN— high blood pressure), atrial fibrillation (AFib— a heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and rapidly), hyperlipidemia (HLD— a condition characterized by elevated levels of fats in the bloodstream) and chronic kidney disease (CKD— a progressive and irreversible condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). During a review of Resident 1 ' s History and Physical (H&P) dated 1/17/25 indicated the resident has the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS— a resident assessment tool) dated 3/28/25 indicated Resident 1 ' s cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions intact. The same MDS further indicated Resident 1 was independent for bed mobility and required setup or clean-up assistance for eating, oral and personal hygiene and partial to moderate assistance with showering/bathing, dressing and toileting. During a review of Resident 1 ' s discharge planning care plan initiated 11/27/24 indicated interventions of: provide written and verbal instructions at the patient/family ' s level of understanding, review and discuss discharge plan with resident/family as appropriate. During a concurrent interview and record review on 5/16/25 at 3:15 pm with Case Manager (CM) 1, Resident 1 ' s case manager progress notes for discharge planning were reviewed. The progress notes indicated the resident ' s family member had been contacted a few times for discharge planning but there was not mention in the notes of the resident and if they were made aware of the plan in the last three months. CM 1 verified there were no notes indicating the resident had been involved in the discharge plan and stated there is no way to prove that it was done without a note. Page 1 of 2 055161 055161 05/16/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility ' s policy and procedures titled Resident Rights reviewed January 2025 indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to . be informed of, and participate in, his or her care planning and treatment. During a review of the facility ' s policy and procedures (P&P) titled Discharge Summary and Plan reviewed January 2025, the P&P indicated When a resident ' s discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge . 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family. 055161 Page 2 of 2