La Crescenta Healthcare Center

In the surveyor’s words

From the most serious findings on record at La Crescenta Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 19, 2021

  Based on observation, interviews, and record review, the facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD; a serious and often deadly form of lung infection [pneumonia], acquired by breathing in water droplets caused by the bacteria, [legionella; the bacteria that causes LD]) in the facility's water system that affected 1 of 79 sampled residents (Resident 1) and placed 78 of the 79 residents in the facility's census at risk for developing pneumonia (infection in one or both lungs causes inflammation of the air sacs). The facility had one (1) positive case (Resident 1) of LD on 2/5/2021. […]

• Immediate jeopardy, isolatedF689Jul 19, 2025

  Based on interview, and record review, the facility failed to provide a safe and secured environment for one of five sampled residents (Resident 1), reviewed for accidents/safety, who was identified at risk for elopement (when a person with cognitive [thought process] impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers), wandering (a person that roams around and becomes lost or confused about their location) out of the facility, and at risk for falls by failing to: 1. […]

• Actual harm, isolatedF689Jul 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents reviewed for accidents/hazards received adequate supervision to prevent accidents and injury for one of two sampled residents (Resident 1), who had a recent fall, and who was identified at high risk for falls upon admission on [DATE], by failing to:1. Ensure the facility communicated and provided awareness to licensed nurses (Licensed Vocational Nurse [LVNs 1 and 2] and Registered Nurse [RN] 1) and certified nurse assistants (CNAs 1, 2, 3 and 4) that Resident 1 was identified as high risk for falls due to recent history of falls history of falls and interventions to visually monitor every hour, in accordance with the care plan for falls and the physician order.2. […]

• Actual harm, isolatedF689Dec 14, 2021

  Based on interviews and record reviews, the facility failed to prevent from falling and sustaining injuries for one of two sampled residents (Resident 1), who was high risk for falls, had behaviors of getting up unassisted, and required personal safety devices (equipment and monitoring devices used for the elderly for safety), when up in the wheelchair, failing to: 1. Provide Resident 1 with adequate supervision (refers to an intervention and means of mitigating the risk of an accident) while up in the wheelchair, as indicated in the facility's Fall Prevention-Falling Star Policy to prevent or decrease the risk of injury from falls. 2. […]

• Actual harm, isolatedF580Nov 12, 2021

  Based on interview and record review, the facility failed to notify the resident's physician immediately for one of two sampled residents (Resident 1) for a change in condition for significant decline in physical functioning and left lower extremity pain (LLE) over a nine-day period by failing to: 1. Assess, address, and report Resident 1's complaints of left lower extremity pain and decline in physical function from minimal assistance (person requires less than 25% assistance) for transfers, bed mobility, and ambulation on 2/20/21 to maximum assist (person requires more than 75% assistance) for transfers and bed mobility and inability to ambulate on 2/23/21 after a resident's fall on 2/22/21. The decline in physical function persisted until 3/4/21. 2. […]