Greater El Monte Community Hos

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 9, Resident 11, and Resident 10) were provided with a safe and comfortable homelike environment by failing to ensure Resident 9, Resident 11, and Resident 10's rooms had comfortable and safe temperature levels. This deficient practice had the potential to result in Resident 9, Resident 11, and Resident 10 feeling uncomfortable and placed Residents 9, 11, and 10 at risk to develop hypothermia (a dangerous drop in body temperature) which could lead to health complications and physical declines to Residents 9, 11, and 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to:A. Ensure two damaged canned goods were removed from the usable food-inventory shelf, resulting in unsafe food items stored with products intended for resident consumption. B. Ensure two (2) of four (4) sanitation buckets located in the main kitchen had adequate amount of quaternary sanitizing solution (an ammonium solution used for sanitizing surfaces) for the disinfection of key areas in the kitchen utilized to prepare residents food. These failures had the potential to expose residents to foodborne illnesses (illness caused by food contaminated with bacteria) and contamination due to inadequate sanitation of food-contact surfaces and improper storage of compromised canned goods.

Inspectors wroteBased on interview and record review the facility failed to provide comprehensive care plans (CP) for one of four residents (Resident 2) when Resident 2 did not have a care plan for diabetes mellitus (DM, a disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production). This failure had the potential to result in Resident 2's individualized medical needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care, for one of one sampled resident (Resident 6), who was at risk for the development of pressure injuries (PU/PI - refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) by failing to:1. Conduct an Interdisciplinary Team Meeting (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) when Resident 6 developed a stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PU/PI at the facility. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 5) who had a urinary catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) received proper care and services when Resident 5's urinary catheter was not flushed (the use of a sodium chloride solution to clean out a catheter) as indicated by the Order Information Report, dated 9/25/2025. This failure had the potential to result in blockage to Resident 5's urinary catheter resulting in discomfort or a urinary tract infection (an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of four sampled residents (Resident 11), the enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) water flush bag (bag of fluid used to keep medical tubing clear and free from blockages) was labeled and dated as indicated in the facility's Policy and Procedure (P&P) titled, Administration of Formula Via Feeding Tube, Gravity, Bolus Pump. This failure had the potential to result in medical complications such as infections (the invasion and growth of germs in the body) for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of four sampled residents (Resident 11), as indicated by the facility's Policy and Procedure (P&P) titled, Tracheostomy Site Care, when Resident 11's tracheostomy tube (a breathing tube placed through a surgical opening in the neck) was left soiled on 11/19/2025. This failure had the potential for Resident 11 to develop medical complications such as infections (the invasion and growth of germs in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a tube-feeding syringe containing gastric contents was discarded after use and was not left at the bedside for one of two sampled residents (Resident 10). This failure had the potential to result in bacterial contamination and infections to Resident 10, staff, and visitors who could have encountered the contaminated tube feeding syringe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10's) room environment was maintained in safe, comfortable, and sanitary condition by failing to:A. Ensure no active roof leak was present in Resident 10's room during active rain season on 11/20/2025. B. Prevent and repair visible wall damage caused by wall moisture and due to the leak in Resident 10's room. This deficient practice placed Resident 10 at risk for respiratory irritation, exacerbation of underlying health conditions, and physical decline. Additionally, there was a potential for discomfort to Resident 10, environmental contamination, increased risk of mold growth, and further structural damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for six of six sampled residents' (Resident 3, 4, 5, 7, 8, and 9) rooms. This deficient practice had the potential for residents to be exposed to dirt, mold, and drywall dust, which can lead to a decline in the resident's health and result in irritation of the eyes, skin, nose, throat, and lungs. Additionally, prolonged exposure can cause serious problems such as acute (sudden) respiratory illness, persistent coughing, and asthma (narrowed airways in the lungs that make it difficult to breath).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control protocols for 8 of eleven sampled residents (Resident 1, 2, 3, 5, 7, 9, 10, and 11) by failing to: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 8) was treated with dignity by failing to provide privacy while accessing Resident 8's PEG tube (G-tube, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) during medication administration. This deficient practice resulted in exposure of Resident 8's portion of the abdomen (belly) and had the potential to result in Resident 8's value as human being not respected.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician for one of three sampled residents (Resident 3) when Resident 3's Gastrostomy-Tube (G-Tube, a tube that is inserted through the abdominal wall and into the stomach to provide nutrition and medication) leaked. This deficient practice resulted in delayed provision of necessary care and services to Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of ten sampled residents (Resident 9), received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy to meet Resident 9's needs in accordance with the physician's order and the facility's policy and procedure (P&P) titled, Oxygen Therapy,. This failure resulted in a lower level of 02 therapy delivered to Resident 9 and had the potential to result in hypoxia (low levels of 02 in your body) and the potential to compromise Resident 9's respiratory status and result in respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled resident's (Residents 1, 5, 8, and 9) responsible parties were provided with information regarding formulating advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time). This failure had the potential to result in violation of Residents 1, 5, 8, and 9's rights to make informed decisions regarding advance directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen, when, 1. The dietary cook (DC), who had a beard, was observed without a beard cover while in the food preparation area. 2. The door gaskets (a rubber seal around the door to insulate refrigeration to maintain desired temperature) on Refrigerator 3 was observed torn. The door gasket located on the left had a tear of 9 inches long and the door gasket located on the right had a tear of ¾ of an inch long. 3. The ice machine drainpipe was not located above the water drain. Liquid waste was observed discharging on the kitchen floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate communication device was provided for one of one sampled resident (Resident 8), who was ventilated (a machine to provide breathing for a patient who is physically unable to breathe) and understood primarily Vietnamese. This failure had the potential to result in a physical and psychosocial decline for Resident 8 due to the inability to express specific needs.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 8) was adequately monitored for behaviors to evaluate the effectiveness psychotropic (medication that change the function of the nervous system and result in alterations of perception, mood, cognition, and behavior) medications. These failures had the potential to result in unnecessary administration of medications to Resident 8 and possible side effects of the medication.