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
During a review of the facility's Policy and Procedure (P&P) titled Resident Mobility and Range of Motion dated 7/2017, the P&P indicated Residents will not experience an avoidable reduction in range of motion (ROM).
Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease 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.
During a review of the facility's P&P titled Restorative Nursing Services dated 7/2017, the P&P indicated Resident will receive restorative nursing care as needed to help promote optimal safety and independence.
Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies) During a review of the facility's P&P titled Screening dated 6/2023, the P&P indicated It is the policy of this Rehabilitation Department to complete patient screenings periodically, dependent on the facility policy for screens.The Joint Mobility Screening form is to be completed by PT and/or OT.Types of Screens: Admission, Re-admission, Quarterly, Annually, Change of Condition, Post-fall.Quarterly and Annual screens (both Rehabilitation and/or Joint Mobility Screening forms) may be done as per facility policy and in conjunction with the MDS assessment schedule.
During a review of the facility's Job Description titled Certified Nursing Assistant dated 10/2020, the Job Description indicated Perform restorative and rehabilitative procedures as instructed in accordance with the individualized plan of care.
During a review of the facility's P&P titled Specialized Rehabilitative Services dated 1/2025, the P&P indicated Our facility will provide rehabilitative services to residents as indicated by the MDS. In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel.
Specialized rehabilitative services include the following: Physical therapy; Speech pathology/audiology; Occupational /activity therapy.
Therapeutic services are provided only upon the written order of the resident's attending physician.
055161 08/28/2025
Garden Crest Rehabilitation Center 909 Lucile Ave.
Los Angeles, CA 90026
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.
055161 08/28/2025
Garden Crest Rehabilitation Center 909 Lucile Ave.
Los Angeles, CA 90026
During an interview on 8/28/2025 at 3:40 pm with the Director of
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.