Garden Crest Rehabilitation Center
GARDEN CREST REHABILITATION CENTER in LOS ANGELES, CA — inspection on August 28, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the written order of the resident's attending physician.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Crest Rehabilitation Center
909 Lucile Ave.
Los Angeles, CA 90026
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to ensure to conduct the Joint Mobility Assessment (JMA, a tool that evaluates a joint's ability to move through its full range of motion by measuring flexibility, stiffness, and quality of movement) accurately for one of four sampled residents (Resident 1).This failure had the potential for Resident 1 to experience a decline in Range of Motion (ROM, full movement potential of a joint).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/2/2024, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason).
The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene.
The MDS indicated Resident 1 was dependent on help for showering, bathing herself, lower body dressing, putting on footwear, and taking off footwear.
During a review of Resident 1's JMA dated 5/27/2025, the JMA indicated Resident 1 had minimal - severe loss of lower extremity Passive Range of Motion (PROM, movement at a given joint with full assistance from another person).
The JMA indicated the resident had a diagnosis/condition that put her at risk for contracture development.
The JMA indicated a recommendation for Resident 1 to receive a Physical Therapy (PT) evaluation, and RNA services for PROM of both upper extremities (BUE, arms).
During a concurrent interview and record review on 8/28/2025 at 11:55 AM, with Physical Therapist 1 (PT 1), Resident 1's JMA dated 5/27/2025 was reviewed. PT 1 stated he (PT1) performed Resident 1's JMA on 5/27/2025. PT 1 stated he (PT1) performed resident JMAs through observation and interview. PT 1 stated he (PT1) performed JMAs by asking Certified Nursing Assistants (CNAs in general) for information about the residents (in general). PT 1 stated he (PT1) did not touch the residents (in general) during JMAs. PT 1 stated PROM was not performed when Resident 1's JMA was done on 5/27/2025. PT 1 stated the integrity of a joint could not be determined by looking at the resident.
During a concurrent interview and record review on 8/28/2025 at 1:15 PM, with the Director of Rehab (DOR), Resident 1's JMA dated 5/27/2025 was reviewed.
The DOR stated when performing a JMA the PT was supposed to use PROM.
The DOR stated that when performing PROM, the PT needed to touch the resident.
The DOR stated a JMA could not be performed without moving and touching the resident.
The DOR stated PROM had to be performed when doing a JMA to feel what had happened in the resident's joint.
The DOR stated if a JMA was done without using PROM then the JMA was inaccurate.
During an interview on 8/28/2025 at 3:40 PM with the Director of Nursing (DON), the DON stated if the JMAs were conducted inaccurately, the resident would not get the care they needed.
The DON stated if the JMA was conducted inaccurately the resident would potentially have a decline in ROM.
During a review of the facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.
Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Crest Rehabilitation Center
909 Lucile Ave.
Los Angeles, CA 90026
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 8/28/2025 at 3:40 pm with the Director of Nursing (DON), the DON stated staff (in general) must clean and disinfect all shared equipment in between and after each resident use.
The DON stated it was important to clean and disinfect shared equipment using the appropriate cleaning agent and according to manufacturer's instructions to prevent the spread of infection.
During a review of the Super Sani-Cloth manufacturer's instructions, titled General Guidelines for Use, dated 2021, the guidelines indicated the disposable wipes disinfected surfaces in two minutes and were to be used on hard, non-porous environmental surfaces.
During a review of the facility's Policy and Procedures (P/P), titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 1/2025, the P/P indicated reusable items were cleaned and disinfected or sterilized between residents.
The P/P indicated reusable resident care equipment was decontaminated and/or sterilized between residents according to manufacturer's instructions.
Facility ID: