Monte Vista Healthcare Center

F-F919.

Findings:

1) During an interview on 2/18/25 at 12:50 p.m. with Resident 7, Resident 7 stated Resident 7's call light was not working since last night (2/17/25). Resident 7 stated he was told by the night shift Certified Nursing Assistant (no name given) to Yell for me. Resident 7 stated he was upset that he would have to yell for help. Resident 7 stated he requested staff to fix his call light on 2/18/25.

During a concurrent observation and interview on 2/18/25 at 12:55 p.m. with Certified Nursing Assistant 6 (CNA 6), CNA 6 was observed pushing the button on the call light, and the light inside Resident 7's room and above the door did not turn on. CNA 6 stated, The call light does not work now, the light does not turn on.

2) During a concurrent observation and interview on 2/21/25 at 10:40 a.m. in Bathrooms 1-7 and Rooms A-D with the Maintenance Director (MTD), MTD acknowledged all bathrooms and rooms reviewed need repairs, and the bathroom conditions and room conditions can pose a risk to the resident's health. Bathroom [ROOM NUMBER]-7 and Rooms A-D had multiples issues such as chipped paint, scratches on the doors, unpainted [NAME], unpainted walls, cracked/peeling caulking on the floors. The MTD stated he would immediately fix all areas reviewed.

During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised September 2022, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: Be sure that the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 055817 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055817 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, Policy Statement: Residents are provided with a safe, clean, comfortable and Level of Harm - Minimal harm or homelike environment and encouraged to use their personal belongings to the extent possible. Policy potential for actual harm Interpretation and Implementation: The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, Residents Affected - Some sanitary and orderly environment.

During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personal include but are not limited to: Maintaining the building in good repair and free from hazards. Providing routinely scheduled maintenance service to all areas.

40913

3) During a review of Resident 13's Admission Record (AR), the AR indicated the facility admitted Resident 13 on 10/8/2024, with diagnoses that included cerebral infarction (stroke - sudden death of brain cells in a localized area due to inadequate blood flow), type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine).

During a review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/9/2025, the MDS indicated Resident 13 understood verbal content and was able to express ideas and wants. The MDS indicated Resident 13 had moderate cognitive impairment. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene.

During a concurrent observation and interview on 2/19/2025 at 9:37 AM, in Resident 13's room, with Resident 13. Resident 13 stated the resident's bed control was not working. Resident 13 stated the resident ended up in a certain position for an extended period of time and ended up having pain in the legs. Resident 13 stated Resident 13 had informed almost all the certified nursing assistants (CNA's) assigned to Resident 13 and the CNA's informed Resident 13 they would notify the maintenance staff but maintenance staff never came to fix the bed control. Resident 13 pressed the bed control and the head of the bed (HOB) moved up then Resident 13 pressed the bed control to move the head of the bed down and the HOB stayed in the up position. Resident 13 was stuck sitting up, approximately close to a 90 degree angle.

During a concurrent observation and interview on 2/19/2025 at 9:42 AM, Resident 13 pressed the bed control for the HOB to go down and the HOB went down. Resident 13 stated that's the problem with the bed control, sometimes it works and sometimes it does not work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 055817 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055817 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 During an interview on 2/19/2025 at 3:50 PM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 13's bed control issue was not reported because Resident 13's bed control eventually worked. LVN 2 stated when Level of Harm - Minimal harm or equipment or a device was not working, staff needed to report the issue to maintenance and write the potential for actual harm request on the Maintenance log so the request for repair could be tracked. LVN 2 stated Resident 13 could get stuck in one position if the bed control did not work and Resident 13 could get stuck in one position could Residents Affected - Some cause Resident 13 to experience discomfort.

During an interview on 2/21/2025 at 9:32 AM, with the Maintenance Director (MTD), the MTD stated the MTD fixed Resident 13's bed control two days ago on 2/19/2025 when it was reported to the MTD, the MTD stated

the MTD replaced the bed control and the bed control was working. The MTD stated Resident 13 reported to

the MTD on 2/19/2025 that Resident 13 had reported the issue to the CNA's. The MTD stated the staff needed to write request for repairs in the Maintenance Log because the MTD checked the Maintenance Log multiple times a day. The MTD stated if the request for repair was verbally reported to the MTD, the repair could get missed because the MTD had a lot of other things to do.

During a review of the facility's undated, Maintenance Log, the log indicated there was no request for Resident 13's bed control repair.

During a review of the facility's P&P titled Maintenance Service dated 12/2009, the P&P indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated the functions of maintenance personnel include other maintenance that may become necessary or appropriate.

During a review of the facility's P&P, titled, Work Orders, Maintenance dated 4/2010, the P&P indicated in order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 055817 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055817 B. Wing 02/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 40913 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one kitchen (Kitchen Residents Affected - Few 1) area was kept free of pest. On 2/18/2025, two dead cockroaches were found in Kitchen 1.

This deficient practice had the potential to result in food-borne illnesses (illness caused by food contaminated with infectious organisms) due to harboring of pest.

Findings:

During a tour of the Kitchen 1 on 2/18/2025 at 8:45 AM, there were two dead cockroaches at the back of the walk-in freezer, the roaches were visible when checking the 3- inch gap located between the walk-in freezer and the wall. The Dietary Aide (DA) used a broom to sweep the cockroaches from the back wall. The broom used had dust and green beans that were swept together with the dead roaches.

During an interview on 2/18/2025 at 8:47 AM, with the DA, the DA stated it was dead cockroaches.

During an interview on 2/18/2025 at 2:40 PM, with the Dietary Supervisor (DS), the DS stated the cockroaches could have come out of hiding after the monthly pest control visit more than a week ago. The DS stated kitchen staff needed to clean all areas of Kitchen 1.

During a review of the facility's Policy and Procedure (P&P) titled Sanitization dated 10/2008, the P&P indicated all kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 055817