Health inspection·July 10, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few 1's physician order titled General Order dated 5/15/2025, the order indicated Visual monitoring every hour for Falling Star Program.During a review of Resident 1's care plan titled High risk for falls that may result to physical harm dated 5/15/2025, the care plan indicated a goal developed on 5/15/2025, to decrease the resident's risk of falls and injury with intervention. The care plan interventions with an approach date of 5/15/2025, included Resident 1 to be placed in the facility's Falling Star Program, provide awareness to staff that patient has history of falls and continued to be at risk for falls. The care plan interventions dated 7/3/2025, indicated Visual monitoring every hour for falling star program (two months after Resident 1 was identified as high risk for falls on 5/15/2025)During a review of Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2025, the MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal; hygiene and dressing and substantial/maximal assistance (helper does more than half the effort) with bathing and toileting. During a review of Resident 1's facility document titled SBAR [Situation, Background, Assessment, Recommendations] - General (document used for residents change of condition), dated 6/19/2025 timed at 7:37 AM, the SBAR indicated at 7:30 AM, Resident 1 complained of right knee pain, and had discoloration (bruising) on the right knee and right inner thigh. The SBAR indicated [Resident 1] was unable to move her right leg due to pain. The SBAR indicated the resident was confused because she was trying to get out of bed .The SBAR indicated pain medication was given for pain management. The SBAR indicated the physician was made aware, and X-ray (used to create images of the inside of the body) was ordered. The document indicated on 6/19/2025 timed at 2 PM, the X-ray result indicated an acute comminuted right intertrochanteric fracture. The document indicated, at 3:40 PM, Primary Medical Doctor (PMD) ordered to transfer Resident 1 to [GACH] 1. During a review of Resident 1's physician order, dated 6/19/2025, the order indicated Resident 1 was transferred to [GACH 1] for further evaluation of acute comminuted right intertrochanteric fracture.During a review of Resident 1's GACH 1 Records titled Emergency Department Reports (EDR), dated 6/19/2025, the EDR indicated Resident 1 presented to the GACH 1 Emergency Department with right hip tenderness (sensitivity to pain) due to a right hip fracture. The EDR indicated under Medical Decision Making indicated Patient [Resident 1] seen and evaluated and given the presentation, the diagnoses included but not limited to fracture, fall, UTI (urinary tract infection - infection of the urinary system), no dislocation, contusion (a bruise). During a review of Resident 1's GACH 1 Records titled History and Physicals (H & P), dated 6/19/2025, the H & P indicated Resident 1 was recently admitted to GACH 1 after a fall leading to an insufficiency fracture (a crack in a bone that occurs without a definite injury). The GACH 1 record indicated Resident 1 was residing at a facility and had a fall a few days ago. The GACH 1 record indicated the X-ray report was consistent with a right intertrochanteric fracture.During a review of Resident 1's GACH 1 Records titled Surgery and Procedure Reports (SPR), dated 6/20/2025, the SPR indicated Resident 1 had a surgery of the right femur.During a review of Resident 1's GACH 1 Records titled Discharge Summaries Notes (DSN), dated 6/23/2025, the DSN indicated Resident 1 had a hip and femur fracture repair. The DSN indicated Resident 1 was transferred to another facility for rehabilitation on 6/23/2025. During phone interview on 7/3/2025 at 10:20 AM with Resident 1's family member (FAM 1), FAM 1 stated, Resident 1 was alert and able to verbalize her needs. FAM 1 stated, someone in the facility called him on 6/19/2025 and informed him that Resident 1 had a fall and sustained a fracture and will be transferred to GACH 1. FAM 1 stated, Resident 1 was still at GACH 1 and had surgery because of the fracture. FAM 1 stated to call Resident 1 in GACH 1. During phone interview on 7/3/2025 at 10:35 AM with Resident 1, Resident 1 stated, she was still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 2 of 5 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 07/10/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few recovering at [GACH 1] at this time because she had a fall at the facility. Resident 1 stated she was getting up from her wheelchair when her wheelchair moved, and she fell on the ground. Resident 1 stated, she could not remember when, where and the time she had the fall. Resident 1 stated, she could not remember how she got up or who helped her get back on her wheelchair after the fall.During an interview on 7/3/2025 at 10:50 AM with CNA 1 (worked 7 to 3 shift on 6/15, 6/17, 6/18, and 6/19), CNA 1 stated, in the morning of 6/19/2025 (7AM to 3 PM shift), not sure of the time, CNA 1 noticed Resident 1's right leg was swollen and had purple discoloration, so she informed her supervisor (RN 1). CNA 1 stated, she was not aware if Resident 1 had a fall prior to the morning shift. CNA 1 stated she was not aware if Resident 1 was on any type of special monitoring such as every hour visual monitoring for risk for falls. CNA 1 stated she normally checks on Resident 1 every two hours during her shift. During an interview on 7/3/2025 at 11:40 AM with LVN (license Vocational Nurse) 1, LVN 1 stated, she was the licensed nurse assigned to Resident 1, in the morning (7 AM to 3 PM) of 6/19/2025, when CNA 1 reported to RN 1 that Resident 1's right leg had purple discoloration and swollen. LVN 1 stated that Resident 1's primary medical doctor (PMD) ordered x-ray which showed fracture to the right leg. LVN 1 stated Resident 1 was sent to [GACH 1] for further evaluation. LVN 1 was asked if Resident 1 was on frequent visual monitoring and why. LVN 1 stated she was not sure if Resident 1 was on visual monitoring and unsure if the monitoring was every one hour or every two hours. LVN 1 stated, the previous shift (11 PM to 7 AM) did not mention if Resident 1 had a fall during their shift. During an interview on 7/3/2025 at 1:35 PM with CNA 2 (worked 3 PM to 11 PM shift, on 6/14, 6/15, 6/18 and 6/19), CNA 2 stated, she knows Resident 1, and normally checks on Resident 1 every 2 hours just like every other resident on her assignments. During an interview on 7/3/2025 at 1:45 PM with CNA 3 (worked 11 to 7 shift on 6/18/2025), CNA 3 stated, she knows Resident 1, and did not know if Resident 1 was not on any special type of frequent visual monitoring, so she checks on her four times a shift (approximately every two hours in an 8 hour shift) and normally checks on this resident every 2 hours just like every other resident on her assignments.During an interview on 7/3/2025 at 2 PM with CNA 4 (worked 7 to 3 shift on 6/14/2025), CNA 4 stated, he knows Resident 1, and CNA 4 was not aware of her every one-hour visual monitoring for risk for falls.During an interview on 7/3/2025 at 2:05 PM with LVN 2, LVN 2 stated, she knows Resident 1, but was not aware Resident 1 had a history of fall nor on one-hour visual monitoring for risk for falls.During an interview on 7/9/2025 at 2:20 PM with Treatment Nurse (TN) 1, TN 1 stated, she worked on 6/19/2025 in the morning shift (7 AM to 3 PM). TN 1 stated, there was bruising and purple discolorations on Resident 1's right knee and right inner thigh when she observed the resident on 6/19/2025, prior to [GACH 1] transfer. During an interview on 7/9/2025 at 2:30 PM with RN (Registered Nurse) 1, RN 1 stated, she worked on 6/19/2025, in the morning shift (7 AM to 3 PM). RN 1 stated, she assessed Resident 1 right away when CNA 1 told her about the bruising found on Resident 1' s right knee and thigh. RN 1 stated, there was quite a bit of discoloration/bruising on Resident 1's right knee and thigh so she notified the PMD on the same day (6/19/2025) and X-ray and blood tests were ordered. RN 1 stated, Resident 1 was transferred to [GACH 1] on 6/19/2025, for further evaluation. During an interview on 7/9/2025 at 3:20 PM with RNA 1, RNA 1 stated, she works five days a week doing Range of Motion Exercises (ROM) for the residents. RNA 1 stated, she is aware of the facility's Red Star Program for those residents who were identified at risk for falls. RNA 1 stated, RNAs does not have a list of residents included in the Red Star Program, and she was not aware that RNAs were responsible to ensure residents on the Redstar program had visual identifier. During a concurrent observation inside the facility's Dining Room (DR) and interview with the MDS Nurse (MDSN), on 7/9/2025 at 4 PM, a facility record titled Resident on Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 3 of 5 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 07/10/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few Fall Monitoring dated 5/28/2025, was observed posted on the wall of the DR. During the interview, the MDSN stated, the posted record is the document posted for the facility staff to monitor for fall. The posted record indicated a list of eight resident names and room numbers. The posted record further indicated Monitor (staff in charge) CNA, please remind assigned CNAs to change the residents for incontinent episodes . The posted record further indicated in bold letters Residents Must Be Checked. During the record review, the posted record did not include Resident 1's name on it. The MDSN stated, there was another list for the facility's Red Star Program, but the resident's list was not posted anywhere. The MDSN could not answer why the resident's list for the facility's Red Star Program was not posted for facility staff information and why Resident 1's name and room number were not included on the posted record list for the facility staff to include in monitoring for residents on fall monitoring, as indicated from Resident 1's Fall Risk Data Collection dated 5/14/2025. During a concurrent interview and record review, on 7/9/2025, at 4:15 PM, the Administrator (ADM) handed over a resident's list titled Red Star (undated) that included 22 residents' names and their corresponding room numbers. The undated Red Star list did not include Resident 1's name and room number. The ADM stated, she got the Red Star list from the facility's internal records. The ADM did not have an answer as to why Resident 1 was not on the Red Star list as indicated in the IDT recommendations on the Fall Risk Data Collection dated 5/14/2025. The ADM stated she did not know why the Red Star list was not posted for facility staff to be aware on who are all the residents to be monitored for fall risk. The ADM was asked if she can provide the list of residents included in the Red Star list for May and June 2025 and stated she was not able to find the lists of residents for these months.During a concurrent interview and record review of the facility's P&P titled Falling Star Program, provided by the facility's Administrator on 7/9/2025, at 4:17 PM, the ADM stated the facility uses this specific policy to implement the facility's Falling Star Program. During the concurrent review of the policy, the policy indicated The Restorative Nursing Assistant (RNA) will be responsible for checking of the [residents'] visual identifiers during daily rounds. During the concurrent interview, the ADM did not have an answer as to why the RNAs were not aware of checking identifiers for residents identified as high risk for falls and included in the Falling Star Program. The ADM stated there was another policy for the Falling Star Program specific for the RNAs but could not find it at this time. During a concurrent interview and record review of Resident 1's care plan (CP) for falls developed on 5/15/2025, on 7/9/2025, at 4:30 PM, the MDSN stated the indicated care plan intervention in the CP included Resident 1 was placed in the facility's Red Star Program. The MDSN stated the CP also indicated the intervention of visual monitoring every hour was just added on 7/3/2025 (35 days after the unwitnessed fall on 6/19/2025). The MDSN stated since the care plan interventions for every hour monitoring was just added on 7/3/2025, that means Resident 1 did not have hourly visual monitoring implemented prior to 6/19/2025 (unwitnessed fall).During an interview on 7/9/2025 at 4:50 PM, the MDSN stated, he was aware Resident 1 was assessed on 5/14/2025 for high fall, with the planned interventions to place Resident 1 on the facility's Red Star Fall Program with visual checks every hour. The MDSN did not have an answer as to why Resident 1 was not included on the list of Red Star Residents provided by the ADM and did not know why the RNAs were not aware of the responsibility to check visual identifiers of the high fall risk residents. The MDSN stated, the intervention of visual monitoring every hour due to Resident 1's risk for falls should have been initiated upon admission on [DATE] and not just added on 7/3/2025, to ensure facility staff had the proper guidance to prevent and protect from falls. The MDSN stated, since there was no intervention of visual monitoring every hour there was no guidance to how to take care of Resident 1, and if no guidance, Resident 1 had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 4 of 5 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 07/10/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete potential for recurrent falls or accidents. A review of the facility's P & P titled, Fall Management (undated), the P&P indicated: a)based on previous evaluation and current data, staff will identify interventions related to resident specific risk and causes to try to reduce the risk of resident falling, and try to minimize complications from falling, b) any resident admitted will have a fall risk data collection form completed, a score of fourteen (14) or above is considered a high fall risk, a fall prevention plan will be implemented (Falling Stars Program).A review of the facility's policy and procedure (P & P) titled, Falling Star Program (undated), the P&P indicated the following information: - The purpose of the Falling Star Program is to identify residents at highest risk for falls and/or injuries and designed to monitor residents and determine the predisposing factors and underlying reasons for fall incidents, develop and implement a plan of care to minimize the risk for fall or major injuries . Use of visual identifiers to alert staff of the residents' high risk for falls and/or injuries would be implemented. -The red star will be affixed by the license Nurse/Designee in the resident's name at the room entrance, on top of the resident ‘s bed, in the wheelchair and/or walker, and a red name band. If the resident has Fall Risk Data Collection Score of 14 and above, along with following additional criteria: 1. Resident has more then one (1) fall within the last ninety (90 days). 2. Resident has history of major injuries, including but not limited to a fracture. -The facility's IDT will review the Fall Risk Data Collection and conduct resident observations, discuss during the schedule meeting (i.e., weekly Fall Risk Meeting), evaluate the resident's status, and determine if the resident will need to continue being included in the program or will need to discontinue if resident is no longer deemed appropriate for the program.-Individualized plans of care will be implemented by the IDT to minimize the risk of resident of falling with major injuries. Sample strategies. Depending on resident-specific care needs are as follows: 1. Creating an area for residents on high risk for falls/injuries. 2. Staff assigned in the designated area will be provided ongoing training on fall prevention strategies. 3. Specialized activity programming for the residents designated area to meet the resident preferences, including a happy feet program 4. Scheduled safety rounds with assigned staff.-Restorative Nurse Assistant (RNA) will be responsible for checking of the visual identifiers during their daily rounds. A review of the facility's P & P titled, Safety Supervision of Residents 8/23/2024, the P&P indicated: 1. Resident safety and supervision and assistance to prevent accidents are company-wide priorities.2. Implementing interventions to reduce accident risk and hazard shall include communicating interventions to all relevant staff and assigning responsibility to carrying out interventions, and ensuring interventions are implemented. A review of the facility's P & P titled, Comprehensive Plan of Care (undated), the P&P indicated that comprehensive plan of care must address the resident's individual needs, reflect interventions to meet short- and long-term resident goals and include interventions to attempt to manage risk factors. Event ID: Facility ID: 055960 If continuation sheet Page 5 of 5