Monterey Park Conv Hosp

In the surveyor’s words

From the most serious findings on record at Monterey Park Conv Hosp, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF600Aug 24, 2026

  Based on observation, interview, and record review, the facility failed to prevent physical abuse (willful infliction of injury which includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for two (2) of three sampled residents (Resident 1 and 2) by implementing the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, and Exploitation revised 12/19/2022 and P&P titled, Accidents and Supervision revised on 12/19/2022. This failure has resulted in Resident 2 hitting Resident 1 on the head on 8/12/2026, leaving Resident 2 with head injury, left scalp laceration, and left upper lip laceration while Resident 2 suffered from a right-hand abrasion and potentially put both residents at risk for mental and emotional distress. Findings1. […]

• No harm, potential for more than minimal, patternF812Jul 2, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF880Jul 2, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF578May 15, 2025

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF700May 15, 2025

  Based 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. […]