Health inspection·December 10, 2024

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 ensure a personal safety alarm (PSA: any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) was placed on one of two sampled residents (Resident 1) bed, who was assessed as a high risk for fall, in accordance to the facility ' s policy and procedure (P&P) titled, Personal Safety Alarm. This deficient practice had the potential for a delayed response from facility staff when Resident 1 attempted to get out of bed unassisted, potentially resulting in falls. Findings: During areview of Resident 1 ' s Face Sheet, the Face Sheet indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), history of pelvis fracture, history of falling, and osteoporosis (a bone disease that weakens bones, making them more likely to break). During areview of Minimum Data Set (MDS - a resident assessment tool), dated 9/4/2024, the MDS indicated Resident 1 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) eating, bathing, dressing and personal hygiene, and required substantial/maximal assist (helper does more than half the effort) with walking 150 feet. During areview of Resident 1 ' s facility document titled Fall Risk Data Collection dated 9/4/2024, , the Fall Risk Data Collection indicated Resident 1 score was 14, indicating Resident 1 was considered ahigh risk for fall resident. During areview of Resident 1 ' s facility document titled, Observation Detail List Report for Situation, Background, Action, Response (SBAR) – Fall dated 10/21/2024, the SBAR indicated Resident 1 was found in Resident 1 ' s room sitting on the floor. During areview of Resident 1 ' s facility document titled Fall Risk Data Collection dated 10/21/2024, the Fall Risk Data Collection indicated Resident 1 ' s score was 18, indicating Resident 1 was considered ahigh risk for fall resident. During a review of Resident 1 ' s facility document titled Observation Detail List Report SBAR – Fall dated 11/27/2024, the SBAR indicated Resident 1 was found in Resident 1 ' s room on the (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 3 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 12/10/2024 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)