Monterey Park Rehabilitation & Health Care Center

Inspectors wroteBased on observation, interview, and record review, the staff member working in the kitchen failed to wash their hands, providing a risk of cross contamination between objects and food. This practice potentially affected all residents who ate the food from the kitchen. The facility census was 98 residents. Review of the facility's undated Handwashing Policy and Procedure showed:-Hand washing was the most important component for preventing the spread of infection. Proper hand washing technique was to be used at all times that hand washing is indicated.-Hand washing was to be done:--When hands were visibly soiled.--Before and after eating or handling food.--After toileting or after personal grooming (combing hair).--Before starting work.--After smoking.--After coughing, sneezing, or blowing your nose.--After handling uncooked animal products such as raw meat, or fish.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's emergency contact in a timely manner for one sampled resident (Resident #54) when on 9/11/25 at 8:10 A.M., he/she had weakened knees that buckled resulting in staff lowering him/her to ground. out 21 sampled residents. The facility resident census of 98 residents. A policy related to Notification of Change was requested not received at time of exit. 1. Review of Resident #54's admission Record form showed the resident was admitted on [DATE] with diagnoses of:-History of falls. -Cerebral Infraction (stroke happens when there is a loss of blood flow to part of the brain). -Cognitive Communication Deficit (condition where a person has difficulty with communication because of a disruption in brain function that affects thinking abilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one mechanical lift in resident room [ROOM NUMBER], free from a buildup of grime and particles. This practice affected one resident who was dependent on the use of a mechanical lift. The facility census was 98 residents. Review of the facility's Undated guidelines for inspecting the mechanical lifts, entitled Inspecting Mobile lifts, showed: -Inspect all surfaces on lifts to ensure they are in good repair.-Clean as necessary and notify housekeeping.-Check battery if applicable.-Inspect the control panel.-Inspect the electrical cords.1. Observations on 9/23/25 at 11:52 A.M. and on 9/25/25 at 12:58 P.M., showed a buildup of grime on the base of the mechanical lift in the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one sampled resident (Resident #18) out of 21 sampled residents. The facility census was 98 residents. A call light policy was requested and not provided at the time of exit. 1. Review of Resident #18's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/30/25 showed:-The resident was moderately cognitively impaired. -Required staff assistance with his/her activities of daily living. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices for proper placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) tubing from dragging or touch the ground, for one sampled resident (Resident #10) who's at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 21 sampled residents. The facility census was 98 residents. Review of the facility Indwelling Foley Catheter Care policy dated 12/2024 showed: -Ensure resident to keep the catheter and tubing free of kinks. -Check drainage tubing and bag to ensure that the catheter is draining properly. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one sampled resident (Resident #1) out of four sampled residents received medications as prescribed by the physician. On 7/9/25 Certified Medication Technician (CMT) A failed to verify the identity of the residents prior to administering medication and failed to update the resident's bed location in the electronic medication administration (eMAR) system, resulting in Resident #1 receiving Resident #2's medications. The facility census was 95 residents. On 7/21/25 the facility Administration was notified of the past noncompliance which occurred on 7/9/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/10/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when one staff member (Dietary Manager) spoke in a harsh tone and showed aggression to one sampled resident (Resident #2). The facility census was 97 residents. On 7/9/25 the facility Administration was notified of the past noncompliance which occurred on 6/18/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/7/25. A facility policy for dignity and respect was requested but not provided.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff administered the wrong medications to one sampled resident (Resident #1) out of six sampled residents. The facility census was 95 residents. On 2/4/25 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 1/31/25. On 1/31/25 the facility Administrator was notified of the incident and the investigation was started. Certified Medication Technician (CMT) A notified Licensed Practical Nurse (LPN) A of an medication error he/she had made. CMT A and all nursing staff were educated on medication administration on 1/31/25. The deficiency was corrected on 1/31/25. Review of the facility Medication Pass Tips dated 5/2019 showed: -The following is a compilation of points to keep in mind during medication pass. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate transfer techniques were utilized for two sampled residents (Resident #1 and #3) out of four sampled resident. The facility census was 94 residents. Review of the facility's Transfer-One Person Skills Checklist: -Check [NAME] for appropriate transfer technique. -Position chair, wheelchair, commode to resident's strong side. -Assist resident to sitting position with feet firmly on the floor. -Apply gait belt. -Have resident place their hands on you shoulders. -If transferring from chair, wheelchair, commode, have resident place hands on arm rests and push up while you pull resident up to a standing position. -Brace knees against resident's knees, or your knees on the outside of the resident's knees to block feet from sliding. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling fans in the South nurses' station sitting area, free of a buildup of dust and failed to maintain the tube feeding poles in resident rooms [ROOM NUMBERS] free of debris on those poles. This practice potentially affected at least 10 residents who used the sitting area and two other residents who received tube feedings. The facility census was 92 residents. Observation on 1/5/23 at 9:45 A.M. with the Maintenance Director showed a buildup of dust on the ceiling fans over the South Nurses' station sitting area. During an interview on 1/5/23 at 9:47 A.M. the Maintenance Director said the housekeepers have extendable cleaners they can use to clean the fans. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two sampled residents (Resident #31 and #80) who had a weight loss of over 10% in the last six months; to ensure monitoring of weight loss interventions was completed to try to prevent continued weight loss for one sampled resident (Resident #80); to ensure health shake supplements were documented to show the amount consumed for three sampled residents (Resident #80, #53 and #81) and to ensure dietary orders were transcribed accurately to dietary meal tickets for two sampled residents (Resident #53 and Resident #81) out of 21 sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Nutrition (impaired)/Unplanned Weight Loss- Clinical Protocol dated January 2017 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% with a medication error rate of 26.92% when Licensed Practical Nurse (LPN) B did not ensure all crushed medication substances in medicine cups were dissolved and given via percutaneous endoscopic gastrostomy (PEG - a tube is a procedure to place a feeding tube) for one sampled resident (Resident #76) and when Registered Nurse (RN) A did not ensure that insulin pens were primed before insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. Review of the facility Enteral feeding Policy dated 1/22 showed: -Flush tubing with with at least 30 ml (milliners) of water or prescribed amounts before and after feedings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained at the appropriate temperature in the North Hall medication room which had the potential to affect all residents in the North Hall. The Facility census was 92 Rresidents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges including: --Refrigeration: 36 degrees to 46 degrees Fahrenheit (F). -Facility should monitor cold storage containing vaccines two times a day per Centers for Disease Control (CDC) guidelines. 1. Review of the North Hall's Refrigerator Temperature Log dated January 2024 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the door to the dessert fridge closed properly; to ensure the baffle (movable metal partitions used to create slotted openings along the back of the hood used to direct the air that is being exhausted out of the hood) were installed in the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease), vents did not have a heavy buildup of dust; and to ensure the upper water nozzles of the dishwasher were maintained free from debris inside those nozzles. This practice potentially affected 90 residents who received food from the kitchen. The facility census was 92 residents. 1. Observation during the initial kitchen observations on 1/02/24 from 9:03 A.M. through 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene during medication pass when passing oral medications and connecting/disconnecting an intravenous (IV) antibiotic to two sampled resident's (Resident #24 and #40) central venous catheter (CVC- a catheter placed in a large vein usually in the chest, neck, or groin to give medications, fluids, nutrition, or blood); during insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48); and to follow appropriate infection control practices to properly change gloves and wash or sanitize their hands during incontinence care for two sampled residents (Resident #59 and #70) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medicine kept in a resident room was properly stored; to ensure there was a physician's order for self-administration of medication, and to ensure the resident was assessed to be able to self-administer medications for one sampled resident (Resident #21) and one supplemental resident (Resident #27) out of 21 sampled residents and 4 supplemental sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a safe transfer for one sampled resident (Resident #80) who needed assistance with transfers and was unable to bear weight, and to ensure the resident was not left sitting up in his/her wheelchair unattended in his/her room to prevent falls out of 21 sampled residents. The facility census was 92 sampled residents. Review of the facility Fall Management policy and procedure revised 9/17/19, showed the purpose of the fall management program was to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promotes safety, prevention and education of both staff and residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with oxygen had physician's orders documented for two sampled residents (Resident #70 and # 83); to ensure oxygen nasal cannulas (a thin flexible tube that gives you additional oxygen through your nose), face masks and tubing was kept covered when not in use for one sampled resident (Resident #83) and ensured free standing oxygen containers were secured in an oxygen stands for two sampled residents (Resident #70 and #83) out of 21 sampled residents. The facility census was 92 residents. Review of the facility's Oxygen Administration policy and procedure dated 1/2027, showed: -Verify that there is a physician's order for this procedure of oxygen administration. -After completing the oxygen set up or adjustment the following should be documented in the resident's medical record: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBCs), and/or the Nurse Aide (NA) Registry were completed and to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for nine out of nine sampled employees. The facility census was 86 residents. Record review of the facility's Abuse, Prevention and Prohibition policy last reviewed 2021 showed: -The facility would not knowingly employee individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. -All employees would have CBCs, State and Federal required background checks. 1. Record review of Employee A's employee file showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen, nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) and/or Continuous Positive Airway Pressure (CPAP-a device that delivers continuous pressurized air through tubing into a mask that you wear while you sleep) equipment was stored using proper infection control practices when not in use for three sampled residents (Resident's #56, #72, and #22) out of 18 sampled residents. The facility census was 86 residents. A policy was requested and the facility did not have a policy on respiratory equipment storage. 1. Record review of Resident #56's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acute respiratory failure (occurs when fluid builds up in the air sacs in your lungs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet sanitary conditions and practice sanitary procedures for food and non-food contact surface areas before, during and after food preparation tasks. This deficient practice of not keeping food and non-food contact surfaces sanitary could, potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partake of the meals prepared by the dietary staff. The facility census was 86 residents at the time of the survey. 1. Observations on 6/6/22 at 8:25 A.M. during an initial brief tour of the kitchen and on 6/8/22 between 5:17 A.M. and 12:10 P.M. in the kitchen during the facility's kitchen inspection, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident's physician when medications were not administered as ordered for one sampled resident (Resident #283) out of 18 sampled residents. The facility census was 86 residents. Record review of facility policy titled Significant Condition Change and Notification dated May 2019 showed: -To ensure that the residents family and/or representative and medical practitioner were notified of a residents change such as medication error. -The licensed nurse would contact the medical practitioner about the medication error. -Prior to medical practitioner being called the nurse will have completed the Situation-Background-Assessment-Recommendation (SBAR) assessment. -Each attempted call will be documented as to the time called, who was spoken to, and what information was given to the medical practitioner. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) for two sampled residents (Resident's #9 and #41) who were discharged from Medicare Part A services and remained in the facility out of three sampled residents. The facility census was 86 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C-09-20) dated 1/9/09 showed: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were observed taken prior to the nurse leaving the room and not left at bedside for two sampled residents (Resident's #20 and #21) who had not been assessed by the Interdisciplinary Team (IDT - attending physician, Registered Nurse (RN) with responsibility for the resident, and other staff deemed appropriate, and the resident and/or resident representative) for their cognitive and physical abilities to safely self-administer medication and for whom there was no care plan showing either resident had the ability to fully or partially self-administer medications out of 18 sampled residents. The facility census was 86 residents. Record review of the facility's Medication Administration policy, dated May, 2019 showed: -Staff were to administer medications safely and appropriately. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and administer a resident's ordered medication for one sampled resident (Resident #283) out of 18 sampled residents. The facility census was 86 residents. Record review of facility policy entitled Medication Administration dated May 2019 showed: -Circle initials on Medication Administration Record (MAR) if medication was not administered as ordered and record a reason in the PRN/Omission section of the MAR. -If medication was ordered but not present, call the pharmacy or the supervisor to obtain the medication. 1. Record review of Resident #283's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acute respiratory failure. -Essential (Primary) Hypertension (high blood pressure). [...]