Health inspection·August 9, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect and promote resident rights for 1 of 3 sampled residents (Resident 1) when LVN 1, CNA 2, and CNA 3, continue to change Resident 1 ' s diaper after Resident 1 refused to be changed. This deficient practice resulted in Resident 1 ' s right hand accidentally hit the bedrail (metal or plastic bars positioned along the side of a bed, also commonly known as side rails) and caused bruising (an injury in which the skin is not broken but is discolored from the breaking of small blood vessels that lie underneath the skin) to the back of the right hand and right wrist area. Findings: A review of Resident 1s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limit to, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder (.persistent and excessive worry that interferes with daily activities). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/15/2024, indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with dressing, partial/moderate assistance (helper does less than half the effort) personal hygiene, and substantial/maximal assist (helper does more than half the effort) with toileting. During a concurrent observation and interview on 8/8/2024 at 11:50 AM with Fam1 in Resident 1 ' s room, Resident 1 on her wheelchair observed with bruise on the back of the right hand and wrist area. Fam 1 stated, the incident happened on Saturday 8/3/2024 and she was told by Licensed Vocational Nurse (LVN) 1, Resident 1 was agitated during diaper change and accidentally hit right hand to the right bedrail causing the bruising. FAM 1 stated Resident 1 behavior was usually calm but gets agitated when woken up or forced to do care she does not like. Fam 1 stated, she told staff months ago to call her if Resident 1 refuses care and gets agitated, she usually can get Resident 1 to calm down. During an interview on at 8/8/2024 at 12:15 PM with certified nurse assistant (CNA) 1 (CNA for 8/8/24), CNA 1 stated, Resident 1 is usually calm, but gets agitated if suddenly awakened and /or do not want care. CNA 1 stated, when refusing Resident 1 would use her hands to push away the care givers. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 055960 Printed: 05/15/2026 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 055960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Crescenta Healthcare Center 3050 Montrose Ave LA Crescenta, CA 91214 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)