Health inspection·August 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe care and services for one of three sampled residents (Resident 1) by failing to: 1.Ensure Certified Nursing Assistant 1 (CNA1) and CNA 2 provided two-person physical assistance (help from two person) when they (CNA1 and CNA2) assisted Resident 1 who had a diagnosis of osteoporosis (weak and brittle bones), contracture (a stiffness, shortening at any joint, that reduces the joint's range of motion) with activities of daily living (ADL's, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, bathing, turning, and eating). This failure had a high potential for Resident 1 to sustain injuries and harm. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), age -related osteoporosis with current pathological fracture (broken bone caused by disease) of the right femur (thigh bone), anxiety disorder (a condition in which a person had excessive worry and feelings of fear, dread and uneasiness), unspecified osteoarthritis, and contracture of unspecified joint. During a review of Resident 1's Care Plan Report dated 4/9/2024 indicated Resident 1 had contractures-multiple joints and was at risk for pain, stiffness, fractures, decrease in range of motion (ROM-how far and in what direction you can a joint or muscle), and other complications. The Care Plan Report indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) including to handle Resident 1 gently during care/ADLs. The Care Plan Report indicated to provide 2 person- assist with ADLs/care. During a review of Resident 1's Initial History and Physical (H&P - a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider) dated 1/17/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. The H&P indicated Resident 1 had a history of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteopenia (low bone mass). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment (difficulty with thinking, learning, and remembering), functional limitation in both upper extremity (shoulder, elbow, wrist, hand), both lower extremity impairment (hips, knee, ankle and foot) that interfered with functions of daily living or place Resident 1 at risk for injury. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort and helper lifts or hold trunk or limbs and provides more than half the effort) from staff for eating, oral hygiene, upper body dressing, and rolling left and right. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on the staff for toileting hygiene, shower/bathe self and lower body dressing with dressing. During a review of Page 1 of 3 055161 055161 08/20/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's SBAR Communication Form (SBAR-a simple, structed way to share important information), Situation (what's happening), Background (relevant history), Assessment (professional judgement), and Recommendation (action to resolve the situation) dated 8/4/2025, the SBAR indicated staff (unidentified) reported Resident 1 had grimacing (expression) of pain on the right hip when doing peri-care (the process of cleaning the genital and anal area). The SBAR indicated Charge Nurse (CN-lead nurse) notified the Registered Nurse Supervisor (team leader for nurses) Resident 1 had right hip swelling, pain when moved, and warm to touch. The SBAR indicated Resident 1 was not able to rate pain (a numbered scale to help understand how much it hurts) level. The SBAR indicated the CN provided Tylenol (pain medication) for relief. The SBAR indicated the Medical Doctor (MD) was made aware and ordered an x-ray (a form of electromagnetic radiation, similar to visible light). During a review of Resident 1's Patient Report dated 8/4/2025, the Patient Report indicated right hip, unilateral (one sided) with pelvis (the bony structure inside your hips, buttocks and pubic region), 2-3 views (images taken from different angels to get a more complete picture) X-ray indicated Resident 1 had an interval development (change or progression) of an oblique (a break in a long bone at a curved or diagonal angle to its length, typically caused by falls or other traumas) and displaced proximal femoral fracture (a fracture in the upper part of the thighbone where the bone fragments have moved out of alignment). During an interview on 8/19/2025 at 10:20 AM, with Licensed Vocational Nurse (LVN)1, LVN 1 stated the plan of care for the residents (in general) included orders, screening, observations, assessments, and the diagnoses of the residents. LVN 1 stated she (LVN1) would check the care plan for interventions, or if there was a change or decline. LVN 1 stated the nursing staff (in general) were responsible for following the care plan. During an interview on 8/18/2025 at 4:05 PM, with CNA2, CNA 2 stated she (CNA2) did not know what osteoporosis was and that she (CNA2) did not get report from the licensed nurses (in general) regarding Resident 1's osteoporosis. CNA2 stated she (CNA2) worked at the facility for 29 years. CNA2 stated she (CNA2) would be assigned to Resident 1 before Resident 1's fracture and that she (CNA2) would provide ADLs to Resident 1 without a two-person assist. CNA2 stated that in the morning of 8/4/2025, she (CNA2) noticed Resident 1's right leg was swollen and warm to touch and reported to a nurse (unidentified). During a telephone interview on 8/19/2025 at 10:59 AM with CNA 1, CNA 1 stated he (CNA1) worked on 8/3/2025 from 11 PM, to 7 PM on 8/4/2025. CNA1 stated he (CNA1) worked alone when he (CNA1) assisted Resident 1 with ADLs. CNA 1 stated Resident 1 was a one -person assist only (a single helper is needed to move or support someone for a task, but the person being helped still does most of the work themselves). CNA 1stated, I can ask for help if repositioning is required. CNA 1 stated osteoporosis has to do with fragile bones. During an interview on 8/19/2025 at 12:37 PM, with Registered Nurse (RN) 1, RN1 stated the licensed nurses (in general) needed to notify the CNAs (in general) regarding the residents' (in general) care plan and what was required during the beginning of each shift. RN1 stated she (RN1) did not know if the CNAs had access to the residents' care plans. RN1 stated the licensed nurses (in general) were responsible for monitoring the CNAs and to notify them (CNAs) how many CNAs were required for ADLs. RN1stated, I'm not sure how communication is monitored to insure care. During a concurrent interview and record review on 8/19/2025 at 2:37 PM, with the Director of Nursing (DON) Resident 1's Care Plan Report dated 4/9/2024, and the MDS dated [DATE] were reviewed. The DON stated Resident 1 had contractures and osteoporosis which was the weakening of bones. The DON stated the staff (in general) needed to be gentle and needed to provide care with two CNAs. The DON stated Resident 1 had contractures and if the CNAs (in general) applied pressure to the weak fragile bones, the bones could break and result in a fracture. The DON stated if Resident 1 required two person-assist during care and there if there was 055161 Page 2 of 3 055161 08/20/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few only one CNA, the CNA would have to push harder to turn Resident 1. The DON stated if Resident 1 required two CNAs but only one CNA would turn, change, and provided care, the pressure applied by the CNA (in general) on Resident 1 to turn, would be higher than if there were two CNAs. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised on 7/2024, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care): mobility (transfer and ambulation, including walking): elimination(toileting). The P&P indicated, A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. and the following MDS definitions: Total Dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised on 3/2022, the P&P indicated Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The P&P indicated The IDT includes but is not limited to the resident's attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on 7/2024, the P&P indicated The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition: at least quarterly, in conjunction with the required quarterly MDS assessment. 055161 Page 3 of 3