Monterey Park Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Monterey Park Rehabilitation & Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 8, 2022

  Based on interview and record review, the facility failed to ensure documentation of ongoing monitoring and assessment of a resident who was at risk to develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #1), which resulted in a new unidentified pressure ulcer to his/her left lower leg discovered when the resident was admitted to the hospital after his/her orthopedic Controlled Ankle Movement (CAM) boot was removed, out six sampled residents. The facility census of 83 residents. […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2025

  Based 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… […]

• No harm, potential for more than minimal, patternF584Jan 8, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF692Jan 8, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF759Jan 8, 2024

  Based 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. […]