GLEN PARK AT MONROVIA

Official classification

Type B

Official code

87208(a)(6)

Regulation authority

CCR

What the official deficiency says

a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties. This evidence has not been met as required by: Based on record review and staff interview, the facility is not following the Plan of Operations regarding the fall policy and procedures, the staff called 9-1-1 without doing an assessment to check for severity of pain and injuries.

Official plan of correction

Executive Director will submited updated Fall policy and procedures and conduct a staff training and send staff training agenda and sign-up sheet to the LPA by the POC due date.

Deadline recorded: Aug 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the Administrator did not comply with the section cited above in that the hot water temperature readings in random resident rooms (#5, #6, #9, #209, #212, #216) were below the required 105 - 120 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction The Administrator agreed to maintain the hot water temperature within the required temperature and will adjust the controls. Administrator will submit a 7-day hot water reading log and maintenance service report/invoice to CCL/LPA by POC due date.

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observatio, the Administrator did not comply with the section cited above in that In some of the observed bathrooms, there were no grab bars and non-skid mats which poses/poned a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator will ensure that grab bars and non skid mats are maintained in the residents' bathrooms/community shower room. Administrator will submit photos of the bathrooms with grab bars/non skid mats to CCL/LPA by POC due date.

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the Administrator did not comply with the section cited above in that the exit points of the building, including the residents' rooms, had no signal systems which poses/posed a potential health, safety or personal rights risk to residentsns in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator agreed to contact the signal system company to install the system in the all the residents' units and building's exit points. Additionally, Administrator will submit the facility's plan of correction and/or receipt for service from signal system company to CCL/ LPA by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff... This requirement is not met as evidenced by: Based on interviews and review of documentation, R7's Medication Administration Record (MAR) for July 2024 is inaccurate. Staff initialed the medication log from July 2-8 2024 when R7 was hospitalized and has already left the facility which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR). Administrator to re-train staff on medication management and documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

Deadline recorded: Jul 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: During investigation it was found that the alleged incident did occur as R1 ate food that contained medication that was prescribed to R2 in error.

Official plan of correction

Administrator/Licensee to conduct a training in medication management and medication administration. Copies of Training and Training Log with Participants to be provided to LPA. **incident took place on 1/18/24 and facility held staff training on 1/23/24 - all copies of taining were provided to LPA during visit**

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

874699(c)(3)

Regulation authority

CCR

What the official deficiency says

87469 87469 Advanced Directives and Requests Regarding Resuscitative Measures(c)If a resident who has an advance.......... experiences a medical emergency (3) Specifically for a terminally ill resident that is receiving hospice services ............ For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). The requirement is not met by evidenced by interviews and record review, the facility staff did not call 911 until June 5th, 2021 and resident was complaining pain since mid afternoon of June 3rd and even doctor advised to send R1 to hospital which posed an immediate risk to residents in care.

Official plan of correction

The facility will ensure the resident received timely medical care. The administrator will retrain the staff about ensuring all residents are receiving timely medical care and send the training log to LPA by POC due date

Deadline recorded: Jul 13, 2022. A deadline is not proof that correction was completed.