Health inspection·December 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1) after the facility identified a safety concern in which Resident 1's Responsible Party (RP) 1 was observed utilizing the Hoyer lift (a mechanical device used to lift and/or transfer a person) without calling staff for assistance to transfer Resident 1 from the bed to the chair. This deficient practice had the potential for Resident 1's specific care needs and treatment to not be addressed and had the potential for Resident 1 to sustain falls due to unsafe transfers in and out of bed. During a record review of the admission record (AR) dated 12/7/2025, the AR indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle), Abnormal posture (involuntary/rigid body positioning), unspecified dementia (a progressive state of decline in mental abilities). During a record review of Resident 1's History and Physical (H & P) dated 10/7/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated that Resident 1's cognitive skills (related to thinking, reasoning, decision-making and problem solving) were moderately impaired. The MDS further indicated Resident 1 required substantial/maximal assistance on staff for personal hygiene, lower body dressing, shower/bathe self, toileting hygiene, and dependent (helper does all of the effort) on toilet transfers, chair/bed-to-chair. During a review of Resident 1's Care Plan for High Risk for Fall and Injury, revised on 12/19/25, the Care Plan indicated interventions for frequent reminder regarding safety. During a review of Resident 1's Care Plan for at Risk for Falls, revised on 12/19/25, the Care Plan interventions indicated to educate the resident/family/caregivers about safety reminders and to alter remove any potential causes. During a record review of Resident 1's Progress Notes dated 11/17/2025 at 2:58 PM, the Notes indicated that the Interdisciplinary team (IDT - a team of staff, resident or their representative that meet to discuss needed care and treatments of the residents) met with Resident 1's daughters regarding a safety issue in which staff had observed the family transferring Resident 1 from the chair to the bed without the staff assistance. During an interview on 12/29/2025 at 10:41 AM with Resident 1's representative (RP 1), RP 1 stated that RP 1 assists Resident 1 with care at times and that Resident 1 prefers to be suspended up on the Hoyer lift (a mechanical device used to lift and/or transfer a person) when having a bowel movement. RP 1 stated that a couple of weeks ago RP 1 used the Hoyer lift without staff assistance to transfer Resident 1 from the chair to the bed. During a concurrent observation and interview on 12/29/2025 at 1:14 PM inside Resident 1's room, the Hoyer lift was observed next to Resident's 1 bed. Certified Nurse Assistant (CNA 1) stated that Resident 1 required the Hoyer lift for transfers and that CNA 1 had used the Hoyer lift for a transfer for Resident 1 with the assistance from another staff a Restorative Nurse Assistant (RNA 1). During an observation Page 1 of 2 056317 056317 12/29/2025 Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 12/29/2025 at 2:33 PM the Hoyer lift was observed inside Resident 1's room at the foot of Resident 1's bed. During a concurrent interview and record review on 12/29/2025 at 3:45 PM with the Director of Nurses (DON) Resident 1 Progress Notes dated 11/17/2025 at 2:58 PM was reviewed. The progress notes indicated the IDT had a meeting with Resident's 1 family members with the safety concern of family transferring Resident 1 with the use of the Hoyer lift without staff assistance. DON stated the care plan for non-compliance or lack of knowledge was not initiated for Resident 1 to indicate that the Hoyer lift should not to be stored inside Resident 1's room. During a review of the facility's policy and procedure titled, Care Planning, dated 6/12/2025, indicated, that is the facility's policy to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The facility's policy also indicated that the IDT and or a licensed nurse will initiate the care plan, and the care plan will be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. The facility's policy also indicated that the IDT will review the comprehensive care plan as needed at the following intervals including to address changes in behavior and care and other times as appropriate or as necessary. 056317 Page 2 of 2