Garden Crest Rehabilitation Center
Inspection Findings
F-Tag F0688
F 0688
the written order of the resident's attending physician.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Crest Rehabilitation Center
909 Lucile Ave.
Los Angeles, CA 90026
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-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Crest Rehabilitation Center
909 Lucile Ave.
Los Angeles, CA 90026
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-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(having small spaces or holes through which liquid or air may pass) material. The IPN reviewed the Super Sani-Cloth disinfectant wipes manufacturing instructions and confirmed the disinfectant wipes could only effectively be used on hard, non-porous surfaces. The IPN stated Sani-Cloth disinfecting wipes were ineffective for disinfecting cloth gait belts because they were made of soft, porous materials. The IPN stated
the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use.
The IPN stated it was important to clean and disinfect shared equipment properly and according to manufacturer's instructions to maximize infection control, ensure the cleaning was effective, and to prevent
the spread of infection. 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.
Event ID:
Facility ID:
If continuation sheet
GARDEN CREST REHABILITATION CENTER in LOS ANGELES, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GARDEN CREST REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.