Garden Crest Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for one of three sampled residents (Resident 1) assessed and identified as at risk of wandering(unsupervised movement within a secure area) and elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) on 5/7/2026. This deficient practice had the potential for Resident 1 to have received inadequate care and/or supervision which led to Resident 1's elopement from the facility on 5/11/2026 and sustaining a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately notify the physician of change in treatment when one of three sampled residents (Resident 1) was readmitted back from the General Acute Care Hospital(GACH) after a treatment for ruling out fracture (break or cause to break) on 12/27/2025 with right arm device upon readmission. This deficient practice has the potential for Resident 1 not provided with proper care and treatment from the Primary Care Physician (PCP). During a record review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with a diagnoses of type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed one of three sampled residents (Resident 1) by not: Completing a comprehensive assessment for one of three sample Residents (Resident 1) after readmission from General Acute Care Hospital (GACH).2. Informing and obtaining order from the Primary Care Physician (PCP) of the discharge instruction of for application, splint (a support device made of hard material that keeps an injured area from moving), right posterior (back) long arm. Developing and implementing resident centered care plan for right arm device for one of three sample residents (Resident 1), 3. Monitoring the use of the right arm device for one of three sample residents (Resident 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate (observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of the medication or biological, and professional standards of practice) was not five percent (5%) or greater. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store over the counter (OTC, medication available without a prescription for treating mild ailments) medications at proper temperature controls in one of one medication stockroom, as per the facility's Policy and Procedure (P&P) titled Storage of Medications dated 5/2025. This failure had the potential to expose medication stored in the stockroom to extreme temperatures leading to a decrease in medication efficacy (how well a medication works or its ability to produce the intended result) and the potential for all 56 residents to receive ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to:1. Ensure three of three dry food storage containers stored in the kitchen's dry storage room, were labeled with a use by date (the last day the manufacturer guarantees the food's peak quality, flavor, and nutrient value). 2. Ensure seven of seven scoops used for dry storage foods were not left stacked upon each other, dirty. 3. Ensure 19 of 19 food dome covers (bell-shaped or dome-shaped lid used to cover food) were not stored next to a trash receptacle used for the disposal of paper towels. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation (claim that someone did something wrong) of misappropriation (taking or using someone else's money or belongings without their permission) of resident property immediately, but not later than 2 hours after the allegation was made to the California Department of Public Health (CDPH) for one out of one sampled resident (Resident 63) on 5/16/2025. As per the facility's policy and procedures (P&P) titled Abuse, Neglect, Exploitation (treating someone unfairly or taking improper advantage of them for personal gain, using a resident's vulnerability, or situation for one's own benefit) or Misappropriation - Reporting and Investigating, dated 1/2025. This deficient practice delayed an onsite inspection by the California Department of Public Health to ensure Resident 63's allegation was investigated. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure 14 out of 18 (room [ROOM NUMBER], 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38) resident rooms met the required 80 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Range of Motion (ROM, full movement potential of a joint) and mobility (ability to move) treatments and services to prevent and/or limit a decline in joint (where two bones meet) for two of four sampled residents (Resident 1 and Resident 3) by failing to ensure to: -Complete a 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 and quarterly for Resident 1. -Follow the Physical Therapy recommendations as indicated in Resident 1's JMA. -Provide Passive Range of Motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 1's right hand as ordered by the resident's physician. -Provide ROM exercises as ordered by Resident 3's physician. [...]

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for two of four sampled residents (Residents 2 and Resident 3) by failing to:-Ensure Restorative Nursing Aide 1 (RNA 1) cleaned and disinfected a gait belt (safety device worn around the waist that can be used to help safely transfer a person from one surface to another) in between use for Resident 2 and Resident 3.-Ensure RNA 1 used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing Restorative Nursing Aide services (RNA, nursing aide program that helps residents maintain their function and joint mobility) services to Resident 2 and Resident 3. These failures placed Resident 2 and Resident 3 at risk for potential infections that could cause a decline in the residents' health and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA1) and CNA 2 provided two-person physical assistance (help from two person) when they (CNA1 and CNA2) assisted Resident 1 who had a diagnosis of osteoporosis (weak and brittle bones), contracture (a stiffness, shortening at any joint, that reduces the joint's range of motion) with activities of daily living (ADL's, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, bathing, turning, and eating). This failure had a high potential for Resident 1 to sustain injuries and harm.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours for one of five sampled residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by the SSA and had the potential for Resident 1 to experience ongoing abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure the policy and procedures for discharge planning were followed for one of three sampled residents (Resident 1). This failure resulted in the resident not being properly informed and involved in their discharge plan.

Inspectors wroteBased on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician ' s order. This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1.

Inspectors wroteBased on observation and interview the facility failed to implement its infection control policy by falling to ensure Certified Nursing Assistant (CNA) 1, Registered Nurse supervisor (RN) 1, and House Keeping (HK) performed hand hygiene (hand washing with soap and water and use alcohol-based hand sanitizer) while entering and exiting residents' rooms [ROOM NUMBERS], touching curtains, and bedside tables in the residents' rooms. These deficient practices had the potential to result in the spread of infectious disease (disorders that are caused by organisms, usually microscopic in size, such as bacteria, viruses, fungi, or parasites that are passed, directly or indirectly, from one person to another).

Inspectors wroteBased on interview and record review, the facility failed to ensure to report the Payroll-Based Journal (PBJ - a method to collect staffing data from nursing facilities) for the 3rd quarter (April 1-June 30). This deficiency resulted in the inaccurate data reporting of direct care staff, providers, and vendors potentially placing the facility at risk of not implementing their policy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 9, 32, and 46), who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency dialysis kit (a collection of supplies that people with kidney disease can use in case of an emergency) at the resident's bedside. This deficient practice had the potential for residents to receive a delayed intervention during accidental bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was treated with dignity to promote enhancements of quality of life for one of three sampled residents (Resident 58). For Resident 58 the Physicians Order for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR, when the heart stops beating, or a person stops breathing, there are no rescue measures taken, including cardiopulmonary resuscitation [CPR] an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) was not honored. This deficient practice resulted in Resident 58 receiving CPR against his wishes and not in accordance with his documented POLST instructions ([DATE]) for DNR when Resident 58 was found unresponsive on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for one of three sampled residents (Resident 16). Resident 16's preferred activity preferences were not included in the Activities care plan. This deficient practice had the potential to prevent Resident 16 from having meaningful activity to promote and enhance the resident's quality of life.

Inspectors wroteb. A review of Resident 214's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a blood clot forms in the brain), hemiparesis (a condition that causes weakness or an inability to move on one side of the body), and dysphagia (difficulty swallowing). A review of Resident 214's MDS dated [DATE], indicated Resident 214 did not have signs or symptoms of cognitive patterns, did not present with symptoms of depressed, hopelessness or feeling down, but presented with feelings of isolation. Resident 214's MDS indicated the resident was dependent for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received a monthly drug regimen review for one sampled resident (Resident 6). Resident 6's psychotropic medications (drugs that affect a person's mental state,Venlafaxine [an antidepressant and nerve pain medication] and Quetiapine [Seroquel], used for bipolar disorder) were not reviewed by the facility pharmacist for three months. This deficient practice caused an increased risk of adverse consequences associated with medication therapy.

Inspectors wroteBased on observation and interview, the facility failed to store food properly in accordance with professional standards of practice when several food items in the kitchen were observed unlabeled and undated. These failures placed the residents at risk for food borne illness or contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 14 out of 29 (Rooms 21, 22, 23, 24,25, 26,27,28, 33, 34, 35, 36, 37, and 38) met the required 80 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dizziness and was administered Meclizine (medication used to prevent and control nausea, vomiting, and dizziness) four times a day, had a comprehensive person-centered care plan with appropriate interventions for Resident 1's physical, mental and psychological wellbeing. This deficient practice caused an increased risk in adverse reactions (unwanted, uncomfortable, or dangerous effects that a drug may have) to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with chronic pain syndrome (pain that lasts for longer than three months), received a Pain Assessment after a change of condition (a decline / worsening or improvement in a resident's mental, psychosocial, or physical functioning). This deficient practice had the potential to negatively affect Resident 1's psychosocial wellbeing and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) thoroughly completed a monthly Medication Regimen Review (MRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences [unwanted, uncomfortable, or dangerous effects that a drug may have] and potential risks associated with medications) for one of two sampled residents (Resident 1). This deficient practice caused Resident 1 to receive medication that was not optimal his medical condition and increased the risk of adverse consequences from the medication therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and procedures and the facility Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) titled Garden Crest Rehabilitation Center COVID-19 Mitigation Plan revised on 7/22/2024, for 3 of 6 sampled residents (Resident 2, Resident 3, and Resident 4) by failing to: 1. Ensure staff discarded and did not reuse their N95 mask (a respiratory protective device designed to form a seal around nose and mouth to achieve very efficient filtration) after exiting a room in the Red Zone (RZ, area for residents who have tested positive for COVID-19). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of state licensure for one of two sampled Licensed Vocation Nurses (LVN 2). These deficient practices had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses documented that: 1) 26 of 26 medications were administered on residents' medication administration record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility) for Residents 2, 5, and 9. 2) Eight of Eight removed narcotic medications on the controlled drug record (narcotic sheet - a document to track the administration of controlled substances [narcotic medications which have a potential for abuse and may also lead to physical or psychological dependence]) for Residents 2, 5, 8, and 9. 3) The blood pressures (BP) were taken and or readings recorded prior to the administration of BP medications for Residents 2, 5. These deficiencies had the potential to: 1. Misrepresent the actual medications administered to residents, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two licensed nurses (licensed Vocational Nurse 4 [LVN 4] did not continue to provide care to residents in the facility during the period LVN 4's Cardiopulmonary resuscitation (CPR - is a lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped) certification had expired (no longer valid). This deficiency had the potential for LVN 4 not to stay up to date on the latest CPR techniques and placing the residents at increased risk to experience a decline in health status, function, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and / or implement a resident specific care plan for one of three sampled residents (Resident 1) to monitor and provide interventions for Resident 1 ' s right leg contracture (tightening of muscle to prevent normal movement to a body part). This deficient practice caused an increased risk in the worsening of the right leg contracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to: 1. Ensure two of 16 sampled facility staff (Maintenance Assistant [MA] and Laundry 1 [LD1]) were wearing a mask while working together at the laundry room. 2. Ensure one of 16 sampled facility staff (Dietary Aid [DA1]) was wearing proper N95 (filtering facepiece respirator). DA1 modified the N95 mask with straps placed around his both ears. DA1 ' s N95 was also observed not covering his nose. 3. Ensure two of six sampled facility staff (Licensed Vocational Nurse 1 [LVN1] and Certified Nursing Assistant 2 [CNA2]) were wearing proper N95 fit tested mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. [...]

Inspectors wrotec. A review of Resident 48's admission Record indicated the facility admitted Resident 48 on 1/26/2022, with diagnoses including repeated falls and pneumonia (an infection that inflames the air sacs in one or both lungs). A review of Resident 48's MDS dated [DATE], indicated Resident 48 had moderately impaired cognition and the resident required limited assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, walk in room and corridor, dressing, toilet use, and personal hygiene). A review of Resident 48's Physician's History and Physical (H&P) dated 1/27/2023, indicated the resident had fluctuating (changing) capacity to understand and make decisions. A review of Resident 48's Physician's Orders dated 6/7/2023, indicated to place a wander guard alarm on the resident at all times during every shift. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure their medication error rate was less than five percent (%). Five medication errors out of 30 total opportunities contributed to an overall medication error rate of 16.67 % affecting two of six residents observed for medication administration (Residents 113 and 363). The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 113 and 363 can potentially experience health complications related to delayed medication administration times and one missed medication which could have negatively impacted Resident 113's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness as evidenced by failing to label and date various food items and failing to dispose of food items past their use by and/or expiration date. These deficient practices had the potential to place residents in the facility at risk for food borne illness and/or contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident for 14 of 29 resident rooms (Rooms 21, 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, 38). This deficient practice resulted in inadequate maneuvering space for one of thirty three sampled residents (Resident 113) and insufficient working space for provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect for two of six sampled residents (Resident 30 and Resident 39) by standing over the residents while assisting them during a meal. This deficient practice had the potential to affect residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy titled Answering the Call Light, for one of 36 sampled residents (Residents 263). This deficient practice had the potential to result in a delay in care and services and the resident's inability to ask for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's notice of transfer was provided to the resident's responsible party and to the State Long Term Care Ombudsman (public advocate) as soon as practicable for one of three sampled residents (Resident 46). This deficient practice had the potential to result in the resident's responsible party being unaware of how to contact the State agency and how to appeal a discharge or transfer if necessary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) was administered as ordered for one of 33 sampled residents (Resident 165). This failure had the potential to cause malnutrition and increase Resident 165's blood sugar.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Oxygen Administration policy and procedure for one of 36 sampled residents (Resident 24). Resident 24 was administered oxygen with no physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on interview, and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to administering psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 25). This deficient practice denied Residents 25's right to be informed regarding the risks and benefits of psychotropic medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard a bottle of Humulin R U-100 insulin (a short-acting medication used to treat high blood sugar) with an opened date of 10/1/2023 according to the manufacturer's requirements, affecting Resident 8 in one of two medication carts inspected (Medication Cart A). The deficient practice of failing to discard opened bottle of Humulin insulin within the date recommended by manufacturer (28 days after the open date) resulted in Resident 8 receiving 12 expired doses between 10/30/2023 and 11/14/2023.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to revise a care plan for at risk for falls for one of two sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for recurrent falls.