A list of the most recent deficiencies for La Crescenta Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2024-01-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-15 | 2023-12-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-27 | 2023-11-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-28 | 2023-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-28 | 2023-10-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-03-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-03-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-10 | 2022-12-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-11-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2022-10-14 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-09-28 | 2022-10-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-16 | 2022-09-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-16 | 2022-09-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-08-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-25 | 2022-05-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-25 | 2022-05-20 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-11-08 | 2022-01-13 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-11-08 | 2022-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-08 | 2022-01-13 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-11-08 | 2022-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2021-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-12 | 2021-12-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-12 | 2021-12-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-29 | 2021-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-29 | 2021-12-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-29 | 2021-12-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-10-29 | 2021-12-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-29 | 2021-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-29 | 2021-12-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-29 | 2021-12-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-29 | 2021-12-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-29 | 2021-12-08 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-10-29 | 2021-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-29 | 2021-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-12-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-10 | 2021-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-08 | 2021-11-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-05 | 2021-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-19 | 2021-04-15 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-23 | 2019-10-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-09 | 2019-10-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-09 | 2019-10-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-09 | 2019-10-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-09 | 2019-10-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-09 | 2019-10-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-09 | 2019-10-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-09-09 | 2019-10-09 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-09-09 | 2019-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-09 | 2019-10-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-09 | 2019-10-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-09 | 2019-10-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-09 | 2019-10-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-30 | 2019-01-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-11-30 | 2019-01-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-30 | 2019-01-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-30 | 2019-01-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-30 | 2019-01-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-30 | 2019-01-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-30 | 2019-01-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-30 | 2019-01-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-30 | 2019-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-30 | 2019-01-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-11-30 | 2019-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-30 | 2019-01-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
