Health inspection·July 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. implementation of the IJ Removal Plan through observation, interview, record review, and determined that the IJ situation was no longer present, the IJ was removed onsite on 7/19/2025 at 3:25 PM, in the presence of the ADM and the Director of Nursing (DON). After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 2 (noncompliance with the requirements for participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident, but has the potential to result in more than minimal harm that is not immediate jeopardy). The IJ Removal Plan dated 7/19/2025 included the following information: 1. On 7/17/2025 at 2:30 PM, the facility was notified that Resident 1 was missing, the ADM, DON, Marketing Director, Central Supply Personnel, Rehabilitation Director, and Registered Nurse (RN) organized a search of the clinic and surrounding area. 2. On 7/18/2025 at 8 PM, the Regional Director of Clinical Operations provided a one-on-one in-service education to the ADM, DON, and SSD 1. The training covered the following: -Identification of residents at risk of elopement; -Risk assessment and care planning related to elopement; -New policies and procedures for residents' safety during External Medical and other Off-site (not in the facility) Visits for residents identified with risk for elopement. The requirement that the facility staff or a designated resident representative accompany such resident to appointments and the necessity of verbal and documented communication utilizing the consultation packet and providing the information including the Elopement Risk Evaluation Form to the receiving clinic regarding the resident's elopement risk. 3. The facility's Interdisciplinary Team (IDT- a group of professionals from different fields, designed with the purpose of supporting the health and well-being of participants) re-evaluated all four current residents (Residents 2, 3, 4 and 5) identified at risk for elopement and reviewed appropriate interventions. 4. On 7/18/2025, DON and ADM provided in-service training to all available facility staff concerning the elopement risk identification binder and new policy and procedures. In-service will continue approximately from 7/18/2025 to 7/21/2025 until all active facility staff have received the training. Staff on leave of absence or vacation will receive in-service training upon returning to work before the start of their shift. New employees will receive this training upon hire, and it will be repeated by the Director of Staff Development (DSD) annually. 5. Upon admission, the admitting nurse will evaluate each resident for elopement risk utilizing the designated evaluation form. Care plans and interventions should be identified. IDT will review and verify residents at risk have the necessary precautions in place. 6. The DON or a designee will review appointments daily to confirm that any resident identified at risk for elopement will be accompanied by either facility staff or a resident representative. The facility's nursing supervisor is responsible for verifying residents at risk for elopement are properly accompanied to their appointments. 7. Medical record personnel or their designee will conduct weekly audits of residents with off-site appointments and audit results will be submitted to the ADM and DON for follow-up, as necessary. 8. The SSD will review the off-site appointment schedule for residents each weekday and present the report to ADM and DON, and for any resident identified at risk, an arrangement will be made for a staff or a resident representative to accompany resident to appointment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/20/2025, with diagnoses including encephalopathy (a change in brain function due to injury or disease), hypertension (high blood pressure), chronic pulmonary embolism (a blockage in one of the blood vessels in a person's lungs, most often caused by a blood clot that travels from another part of the body), malignant neoplasm (abnormal growth of tissue [cancerous cells] that can travel to other parts of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 2 of 6 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 07/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. body) of the rectum (end part of the large intestine), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P) signed and dated 5/20/2025 by Resident 1's primary physician (Physician 1), the H&P indicated Resident 1 had a diagnosis that included dementia. The H&P indicated Resident 1 needed scheduled treatments at the Oncologist Office located at the General Acute Care Hospital (GACH) 1. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated [requirements imposed by the federal government] resident assessment tool) with assessment date of 5/26/2025, the MDS indicated Resident 1 had moderately impaired (decision poor; cues/supervision required) cognition (the process of knowing and understanding). The MDS also indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral and personal hygiene, upper body dressing, roll left and right, and sit to lying position. The MDS also indicated that Resident 1 used a walker and wheelchair for her mobility and required partial/moderate assistance (helper does less than half the effort) on walking ten feet on uneven surfaces, wheeling 50 feet with two turns, and wheeling 150 feet with a manual wheelchair. The MDS indicated Resident 1 had wandering behavior present that occurred around one to three days during the MDS assessment date During a review of Resident 1's Elopement Risk Assessment (ERA) dated 5/20/2025, the ERA indicated Resident 1 was assessed with the following: Mobility Status: Resident 1's status was marked check for Able to propel a wheelchair. Behaviors: Resident 1's status was marked check for Wanting to go home, to work, or somewhere else. And history of wanting to leave the facility within the last 30 days. The ERA indicated a conclusion that Resident 1 was identified as At risk for elopement. The ERA indicated to develop a care plan for Resident 1's risk for elopement. During a review of Resident 1's care plan for Falls dated 5/21/2025, the care plan indicated Resident 1 was at risk for falls with Fall Risk Assessment score of 18. The care plan indicated that a Fall Risk Assessment with a score of 14 and above is considered high risk for falls. The care plan goal included decreasing the resident's risk for falls and injury with interventions. The care plan interventions included providing assistance with transfers and mobility, and visual monitoring every hour for Falling Star Program. (a fall prevention initiative that uses visual cues to identify residents at high risk of falling. It involves assessing residents, assigning them a fall risk score, and then using signs, such as a falling star graphic on their doors or at their bedside to alert staff to take extra precautions). During a review of Resident 1's Care Plan dated 5/22/2025, the Care Plan indicated that Resident 1 was at risk for elopement and wandering out of the facility. The care plan goals indicated to decrease Resident 1's risk for elopement and wandering out of the facility and provide a safe and supervised environment for wandering. The care plan interventions included avoiding overstimulation (experiencing too much sensory or mental input at once, causing a feeling of being overwhelmed and unable to process information effectively) which can occur in noisy environments, provide activities that will divert resident's attention from wandering, create a secure environment by securing doors and alarms, check the resident's whereabouts and place a wander-guard bracelet (resident's security system that sound off an alarm to alert caregivers when residents have wandered from the protected zone) for elopement precautions. During a review of Resident 1's Physician's Orders dated 5/22/2025, the Physician's Order indicated to place wander-guard bracelet on for elopement precautions and monitor for [wander-guard] proper placement and battery function every shift. During a review of Resident 1's IDT Care Conference Notes dated 5/22/2025, timed at 1:55 PM, conducted with the Social Service Director (SSD) 1 on 7/18/25 at 5:30 PM, the IDT Notes indicated Resident 1's current plan of care was discussed with FM 1 by phone that included fall risk assessment, visual monitoring every hour, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 3 of 6 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 07/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. elopement risk wander guard on the arm and interventions to manage risks. The IDT Note indicated FM 1's plan was to discharge Resident 1 to an Assisted Living Facility (ALF - provides housing and personal care services to individuals who need help with daily activities, but not the level of medical care provided in a nursing home) or Board and Care (refers to a residential care option catering to individuals requiring assistance with daily living activities). The IDT Note indicated the discharge date was not determined yet due to Resident 1's current condition and waiting for progress within 30 days due to encephalopathy and needs improvement in function. The IDT Notes did not indicate how Resident 1 would be monitored/supervised when going out on appointments outside of the facility. During a review of Resident 1's Social Service Progress Note (SSPN) dated 7/3/2025, the SSPN indicated that Resident 1 insists on going to FM 1's home and the facility's SSD 1 attempted to contact FM 1 several times, but FM 1 did not answer. The SSPN also indicated that the SSD 1 discussed with Resident 1 regarding placement to an ALF in which the resident replied, She [Resident 1] will think about it. During a review of Resident 1's Physician's Orders dated 7/14/2025, the Physician's Order indicated a follow-up appointment with the Oncologist at the Oncologist Office on 7/17/2025 at 1:20 PM. During a review of Resident 1's Progress Note (PN) dated 7/17/2025, timed at 12:30 PM, the PN indicated that Resident 1 went to the [Oncologist] appointment and picked up by medical transportation (to the appointment) in stable condition. During a review of Resident 1's PN dated 7/17/2025 timed at 2:30 PM, the PN further indicated that a phone call was received by the facility from the Oncologist Office Staff looking for Resident 1 because [Resident 1] took the restroom keys with her. At 2:30 PM, Driver 1 called the facility and notified the facility that Driver 1 could not find Resident 1 at the Oncologist Office. At 4 PM, the facility's supervisor notified the Police Department that Resident 1 was missing. During a review of a facility record titled Risk Meeting Notes (RMN) dated 7/18/2025, the RMN indicated that Resident 1 did not return from the Oncologist appointment to the facility. The RMN also indicated the following: 1. On admission, Resident 1 expressed the desire to go home with FM 1. 2. The plan is to continue to work and communicate with the Police Department in locating the resident (Resident 1) to ensure safety. The record indicated Will continue to attempt to reach out to FM 1. During an interview on 7/18/2025 at 1:10 PM with the DON, the DON stated, on 7/17/2025 immediately after the medical transportation driver (Driver 1) notified the facility of Resident 1's elopement, the DON went to the Oncologist office and looked for Resident 1. The DON stated that he also searched for Resident 1's home address indicated on the admission Record. The DON stated Resident 1 was alert and oriented and had never attempted to elope or wander during appointments outside the facility. The DON acknowledged that Resident 1 was identified by the facility as being at risk for elopement, and the facility staff did not send a facility staff to provide supervision and stay/accompany with Resident 1 while in the Oncologist Office [on 7/17/2025] because Resident 1 was alert and oriented and able to verbalize her needs. During an interview on 7/18/2025 at 2:10 PM with SSD 1, SSD 1 stated upon Resident 1's admission to the facility, the facility was made aware that Resident 1 was homeless (no home) and FM 1 informed the facility that Resident 1 would need a placement upon discharge. SSD 1 stated that on 7/3/2025, Resident 1 was asking to go to FM 1's house and SSD 1 tried to contact FM 1. SSD 1 stated she did not document in Resident 1's records or progress notes Resident 1's risk for elopement and how Resident 1 would be monitored/supervised when going out to the Oncologist appointments, scheduled outside the facility. During an interview on 7/18/2025 at 2:55 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 did not appear to be a wanderer (a person with dementia roams around and becomes lost or confused about their location). RN 1 stated on 7/17/2025, she escorted Resident 1 on the way out of the facility prior to the Oncologist appointment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 4 of 6 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 07/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. endorsed Resident 1 to Driver 1. RN 1 stated she removed Resident 1's wander-guard battery in front of Driver 1. RN 1 stated she did not want to mention that Resident 1 was an elopement risk in front of Resident 1. RN 1 stated Driver 1 should have been made aware by SSD 1 of Resident 1's risk for elopement. RN 1 stated that it was more appropriate that the facility's SSD (SSD 1) communicate Resident 1's risk for elopement to Driver 1 and the Oncologist office staff, when SSD 1 made the physician appointments for Resident 1. During an interview on 7/18/2025 at 3:40 PM, Driver 1 stated he dropped off Resident 1 at the Oncologist's Office on 7/17/2025 at around 1:15 PM and informed the Oncologist Office staff by saying, Call me when Resident 1 is ready for pick up. Don't let Resident 1 go anywhere else. However, Driver 1 stated he did not receive instructions from RN 1 or any facility staff that he needed to stay and supervise or accompany Resident 1 one-to-one, while in the Oncologist Office. Driver 1 stated he did not receive a call back from the Oncologist office staff that Resident 1 was ready to be picked up, so Driver 1 went back to the Oncologist Office on 7/17/2025 at around 2:15 PM (approximately one hour after dropping the resident off), but Driver 1 stated he did not see Resident 1 at the waiting area of the Oncologist Office. Driver 1 stated the Oncologist Office staff told him (Driver 1) that Resident 1 went to the restroom. Driver 1 stated he then waited for about five to ten minutes more for Resident 1 in the waiting area, but Resident 1 did not come back. Driver 1 stated the Oncologist Office staff tried to find Resident 1 around 2:30 PM but could not find Resident 1. Driver 1 stated he called the facility immediately, when Oncologist office staff informed him, they could not find Resident 1. During an interview on 7/18/2025 at 4:55 PM with the Oncologist Office Staff (OS) 1, OS 1 stated she recalled when checking in Resident 1 for the Oncology (the branch of medicine that studies, diagnoses, and treats cancer) appointment on 7/17/2025 at around 1:10 PM, OS 1 stated Resident 1 was accompanied by only one person (Driver 1) who did not stay with Resident 1, during the appointment. OS 1 stated the person (Driver 1) who took Resident 1 to the Oncology appointment asked what time to pick the resident (Resident 1) up and left the resident in the physician office. OS 1 stated the Oncologist office staff were not informed by facility staff to always supervise Resident 1 due to risk of elopement or that the resident was at risk for elopement. During a follow-up phone interview on 7/22/2025 at 10 AM with the Administrator (ADM), the ADM stated Resident 1 remained missing and had not returned to the facility. During a review of an email communication sent to the California Department of Public Health (CDPH), from General Acute Care Hospital (GACH) 1, who oversee the Oncologist Office, dated 7/22/2025 timed at 10:30 PM, an email communication titled Notification of Potential Reportable Event was reviewed. The email communication indicated that GACH 1 was notified by the Oncologist Office of A potential reportable neglect event. The email further indicated On 7/18/2025, a social worker (unknown) was made aware of an incident that occurred on 7/17/2025. The email indicated that a resident (Resident 1) with history of forgetfulness and dementia who was a patient at the Oncologist Office was dropped off at the Oncologist Office without a caregiver or a chaperone to attend to the resident's needs and Therefore [Resident 1] attended the appointment alone. The email further indicated At the conclusion of the appointment, [Resident 1] checked out the [Oncologist Office] and asked for the key to the restroom which was provided. The patient [Resident 1] did not return to the lobby to return the key. [Oncologist Office staff] went to check on [Resident 1] in the restroom and did not find [Resident 1]. The key was found later in the lobby. Further review of GACH 1's email communication dated 7/22/2025 indicated that [Driver 1] was in the parking lot of the [Oncologist Office] waiting for [Resident 1] did not see Resident 1. The email indicated the Police Department was notified of the concern for missing person. The email further indicated that the facility reported to GACH 1 that this had been a trend for Resident 1 and had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055960 If continuation sheet Page 5 of 6 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 07/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete eloped from the same facility in the past, as well as other facilities. The email indicated that on 7/22/2025, Resident 1 called the Oncologist Office Staff and informed the Oncologist Office that she was safe and staying at FM 1's house at the moment. During a review of the facility's policy and procedure (P&P) titled Safety Supervision of Residents undated, the P&P indicated that resident supervision is a core component of the systems approach to safety. The P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P&P titled Resident Elopement undated, the P&P indicated The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement. Event ID: Facility ID: 055960 If continuation sheet Page 6 of 6