Monterey Park Conv Hosp

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling procedures and to maintain the food service area in a clean and sanitary manner in accordance with the facility's policy and procedure (P&P) when: The clear container of mashed potatoes was not closed properly. The food blender (Blender 1) pitcher had a lingering vegetable smell, and the top cover was peeling off and with food residue. The classic peanut butter jar had peanut butter smeared on the outside of the jar's red lid. The can opener had dry crusted food residue. A bag containing beef patties, cinnamon rolls, and chocolate chip cookies was torn, exposing its contents and the label on the bag was unreadable. The food grater had dry food residue. Blender 2 with a gray plastic insert paddle was chipped, calcified, and had dried food residue. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two (2) of 2 sampled residents (Residents 9 and 13), reviewed for bowel and bladder, as indicated on the facility policy by failing to ensure:1. Certified Nursing Assistant 7 (CNA 7) performed hand hygiene (cleaning hands to prevent germs) after doffing (take off) gloves when providing incontinence (incontinent- a person is unable to voluntarily control their bladder or bowels) care for Resident 9 and before repositioning the resident and touching clean bed sheets.2. CNA 8 doff gloves and performed hand hygiene after providing incontinent care to Resident 13 and before repositioning Resident 13 and touching clean bed sheets. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) of one (1) of 1 sampled resident (Resident 78) reviewed for call devices under the environment care area . This failure had the potential to cause a delay in care for Resident 78 and prevent the resident from receiving the necessary care and services, which could lead to illness or serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform the physician for one (1) of two (2) sampled residents (Resident 71) reviewed for behavior, when Resident 71 had a change of condition (COC - a sudden, clinically important deviation form a resident's baseline in physical, cognitive, behavioral, or functional domains) on 6/29/2026. This deficient practice had the potential to result in a delay in the necessary care and services for Resident 71.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 12) reviewed for unnecessary medications (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when their potential risks outweigh the benefits) had a specific indication for the use of Buspirone (a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]), in accordance with the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medications (drugs that affect a person's mind, emotions, or behavior). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's impaired hearing needs for one (1) of 1 sampled residents (Resident 33) reviewed for hearing/vision. This deficient practice has the potential to delay in the necessary care and services for Resident 33's impaired hearing which can result in ineffective communication.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for risk for fall for (one) 1 of two (2) sampled residents (Resident 41) reviewed for falls after the resident had an actual fall on 6/7/2026. This deficient practice has the potential for Resident 41 to have further falls, which could result in harm and/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with toileting and perineal care (gentle cleaning of the genitals which involves washing, rinsing, and drying the perineum to maintain hygiene, prevent infection, and protect skin integrity) for one (1) of two (2) sampled residents (Resident 1) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) in accordance with the facility's policy. This deficient practice had the potential to result in skin breakdown, incontinence-associated dermatitis (IAD, skin irritation and damage caused by long-term contact with urine or stool, which makes the skin red, sore, and weakened, and can lead to infection), urinary tract infection, and affect resident's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free from accident hazards when the facility failed to ensure:1. Proper disposal of a used vacutainer needle (a specialized, double-ended medical needle used for multi-sample blood collection) when the vacutainer was observed not fully placed into the sharp's container. This deficient practice had the potential to result in accidental needlestick injuries (accidental skin punctures caused by used needles or sharp medical instruments) and possible exposure to bloodborne pathogens (infectious microorganisms present in human blood that can cause disease in humans).2. The wheelchair of one (1) of five (5) sampled residents (Residents 85) reviewed for accidents was locked while the resident was left seated in it and left unattended in the hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled Resident (Resident 9) reviewed for tube feeding (medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) received appropriate gastrostomy tube (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) care by failing to confirm GT placement when Licensed Vocational Nurse 5 (LVN 5) did not check the resident's gastric residual volume (GRV, the amount of fluid that remains in the stomach and can be withdrawn through a feeding tube before giving additional feedings or medications. It helps determine how well the stomach is emptying and whether the resident is tolerating tube feedings) prior to medication administration on 7/1/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered for one (1) of 1 sampled resident (Resident 44) reviewed for respiratory care in accordance with the physician's order and facility policy. This deficient practice placed Resident 44 at risk for hypoxia (a condition that occurs when the lungs cannot get enough oxygen to the blood) causing serious harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate clinical record in accordance with the facility's policy by failing to accurately document the meal percentage on 6/29/2026 for one (1) of two (2) sampled residents (Resident 41). This deficient practice had the potential to affect Resident 41's nutritional assessment, care planning, monitoring of intake trends, and timely identification of nutritional risks or decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential laundry equipment in safe operating condition by failing to remove the lint as scheduled from the lint trap of one of two (2) dryers in accordance with Policy and Procedure (P&P) This deficient practice resulted in lint buildup within the dryer, creating a fire hazard that placed residents and staff at risk of harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe, clean, comfortable, sanitary and home-like environment for one (1) of two (2) sampled residents (Resident 17) reviewed for environment by failing to ensure Resident 17's gastrostomy tube (G-tube pump, an electronic, battery-powered medical device that delivers liquid nutrition, fluids, or medication at a controlled rate directly into a person's stomach through a surgically placed abdominal tube) was free of dried milk residue and the flooring in Resident 17's room was free of dry milk residue. These deficient practices created an unsafe and unsanitary environment for Resident 17 and had the potential to result in accidents and risk of contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the residents receive information to formulate an advance directive for two (2) of two sampled residents (Resident 139 and 141). This deficient practice had the potential for Resident 139 and 141 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use and follow the physician's order for use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for six (6) of 6 sampled residents (Resident 1, 2, 17, 26, 56 and 69), as indicated in the facility's policy and procedure. This deficient practice had the potential to place Residents 2, 17, 26, 56 and 69 at risk for entrapment (residents becomes caught or trapped in spaces around a bed rail) which could result in injury and death. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure Dietary Aide 1 (DA 1) wore hair restraint (worn by food handlers to avoid hair getting into the food) to cover mustache and beard while in the kitchen and food storage areas. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria [tiny, single-celled living things that are found everywhere, including in and on your body] from one place to another) and harmful bacterial growth that could lead to illness for 69 of 80 medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of seven (7) residents sampled for infection control care areas (Resident 49, 50, 56, 69 and 141) and in accordance with the facility's policy and procedure when: 1.a Licensed Vocational Nurse (LVN) 3 failed to don (putting on) an isolation gown prior to entering Resident 49's room who was on a Transmission Based Precaution (TBP - refers to actions [precautions] implemented in addition to standard precautions that are based upon the means of transmission [airborne, contact, and droplet] to prevent or control infections). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was safe and sanitary by failing to: 1. The kitchen ceiling was free from water leak stains, bubbling and paint that was peeling off. 2. One of four dumpsters was completely closed and not overflowing. This deficient practice resulted in an unsanitary and unhomelike environment and had the potential for residents to be placed at risk for serious illness and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 139) was treated with respect and dignity in accordance with the facility policy by failing to keep the resident clean and free from food particles. This deficient practice has the potential to affect the resident's self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 56) psychotropic medication (substance that affect the brain's activities and influence mental processes and behaviors) was appropriate to treat the resident's specific and documented condition in accordance with the facility's policy. This deficient practice placed Resident 56 at risk for unnecessary medication and delayed provision of necessary care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's oxygen needs for one (1) of 19 sampled residents (Resident 141). This deficient practice has the potential to delay in the necessary care and services for Resident 141's oxygen therapy resulting to shortness of breath or other respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent injuries for two (2) of five (5) residents sampled by failing to: 1. Ensure Resident 55's feet were on a footrest while resident was seated on a wheelchair during transport. This deficient practice had the potential to cause Resident 55's feet to drag which could result in serious injuries. 2. Provide padded siderails (a barrier attached to the side of a bed) for Resident 190 who had history of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness). This deficient practice had the potential for Resident 190 to sustain injuries during a seizure disorder activity.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary respiratory care services to one (1) of one sampled resident (Resident 141) by failing to ensure the Resident 1's nasal cannula (NC - a small plastic tube, which fits into the person's nostrils [nasal prongs] for providing supplemental oxygen) for oxygen was placed correctly while the resident is receiving oxygen. This deficient practices have the potential for Resident 141 to develop complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Staffing Report (Nurse Staffing Information) on 5/12/2025, 5/13/2025 and 5/14/2025 was complete and posted in a prominent place readily accessible to residents, visitors, and staff in accordance with the facility's policy and procedure. These deficient practices had the potential for residents and visitors to not be informed of the actual number of nurses providing direct care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 resident rooms, a multiple resident room (Room A) met the minimum square footage requirement of 80 square feet (sq. ft. unit of measurement) per resident. This deficient practice had the potential to affect the care, comfort, and services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision during toileting and failed to ensure the sensor alarm (helps to alert caregivers when a resident gets out of bed in order to ensure resident safety) was functioning for one (1) of two (2) sampled residents (Resident 34), who was at high risk for falls. This deficient practice resulted to Resident 34 had fall on 2/13/2024 and was sent to General Acute Care Hospital (GACH 1) and another fall on 3/23/2024.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Remove an expired Humulin R insulin (Insulin Regular Human - a medication used to treat high blood sugar) vial in the refrigerator. 2. Store five (5) unopened Insulin Glargine Flex Pen (a medication used to control high blood sugar) in the refrigerator. This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. A container of [NAME] was not broken. 2. A container of cookies was sealed properly. 3. A can opener was clean and free of gunk and rust. 4. Trash can lid was closing properly. Trash can was observed to be full beyond capacity. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when two bags of kitchen trash were observed on the ground right outside at the back of the facility kitchen. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy, dignity, and respect for one of four sampled residents (Resident 70) when Licensed Vocational Nurse 2 (LVN 2) did not close Resident 70's door and/or pull the resident's privacy curtain during administration of resident's medication via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach This deficient practice had the potential to affect Resident 70's emotional and mental well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean comfortable, sanitary, and home like environment for three (3) of five (5) sampled rooms by failing to ensure: 1. Rooms A and B's bathroom toilet was free of fecal matter. 2. Room D's bathroom light bulb and wire were covered. This deficient practice caused an unsanitary and unsafe environment and had a potential for residents to be placed at risk for infection and injury.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized baseline care plan with 48 hours of admission for one of 19 sampled residents (Resident 182) who was receiving hemodialysis (process of removing waste products and excess fluid from the body). This deficient practice had the potential not to meet the needs of Resident 182 that included interventions for hemodialysis, safety, and wellbeing, which could lead to harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan for one of five sampled residents (Resident 285) was developed to address non-compliance with medications, as indicated on the facility's care plan policy. This failure had the potential for licensed staff not to utilize interventions for resident to comply with timely administration of medications, which could place Resident 285 at risk for adverse effects from not taking medications as ordered.

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality (care and services are provided according to accepted standards of clinical practice) for one (1) of four sample residents (Resident 18) when Licensed Vocation Nurse 2 (LVN 2) failed to apply gentle pressure to the lacrimal (tear) duct to prevent systemic absorption of the medication of Artificial Tear ophthalmic Solution (a medication used to treat dry eye) during medication administration, as indicated on the facility's Administration of Eye Drop or Ointment policy. This deficient practice had the potential for Resident 18 to have an adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of three (3) sampled residents (Resident 234) was functioning properly. This deficient practice had the potential for Resident 234's pressure ulcer to worsen and for the resident to develop new pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled resident (Resident 182), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care and services by failing to assess the resident's right upper chest dialysis access site on 5/20/2024, 5/22/2024, 5/24/2024, in accordance with the facility policy. This deficient practice had the potential for Resident 182 to suffer from complications such as bleeding or infection from the central venous catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 11) by failing to administer resident's Calcitonin Solution (a medication used to treat bone loss) nasal spray, as indicated on the physician order. This deficient practice had the potential for Resident 11's bone to become more fragile or low in bone mass which could put the resident at a greater risk for fracture (break in the bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order, for one of 19 sampled resident (Resident 24). This deficient practice placed Resident 24 at risk for further decline in physical functioning and decline to perform self-feeding skills.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the facility's infection control policy for one of 19 sampled residents (Resident 70) when staff was observed not using a gown while providing high-contact resident care activities to Resident 70. This deficient practice had the potential to result in Resident 70 developing an infection and spread of infection among staff and residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure a string was attached to the call light in the bathroom for one of 19 sampled residents (Resident 39). This deficient practice resulted in the call light not being easily accessible to Resident 39 which had the potential to result in a delay in the provision of care and assistance leading to falls, accidents, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 resident rooms, a multiple resident room (Room E) met the minimum square footage requirement of 80 square feet (sq. ft. unit of measurement) per resident. This deficient practice had the potential to affect the care, comfort, and services to the residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) when the resident had a change in condition (COC) for a fever (elevated temperature) and episodes of nausea as indicated in the facility's policy and procedure. This deficient practice had the potential to delay medical interventions and treatment for a possible wound infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented medical records for one of two sampled residents (Resident 1) by failing to document the resident ' s elevated temperature from 9/3/2023 until 9/04/2023 at 7 AM. This deficient practice had the potential to cause medication errors, inconsistencies in providing the necessary care and services to Resident 1.