Heritage Manor

F-F695.

Findings:

1. During a kitchen observation on [DATE REDACTED] at 10:46 AM, the dietary staff did not review and follow the recipe to ensure adequate measurement of thickener powder (powder like starch used to thicken the texture of food) were mixed when preparing the pureed food who were prescribed with pureed diet and were served pureed food that was pasty and thick in texture.

During a concurrent observation and interview on [DATE REDACTED] at 1:10 PM with the Dietary Manager (DM), the DM stated the dietary staff did not measure how much the thickener power was put into the pureed food when

they were preparing them. The DM stated someone was supposed to check the final products to make sure texture of the food was correct, but she was not sure which dietary staff was the one in charge of checking

the final product before the tray line and they did not have log of checking the textures of the food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0867 During an interview on [DATE REDACTED] at 2:11 PM with the Cook, the [NAME] stated she did not follow the pureed recipes and did not know if they had the pureed recipes available. The [NAME] stated she added the Level of Harm - Minimal harm or thickener powder by eyeballing the amount of thickener needed, instead of measure it, when preparing potential for actual harm pureed food. The [NAME] stated she and the dietary manager would taste the pureed food and based on her experience to determine if the texture of the pureed food was right. Residents Affected - Some

During an interview on [DATE REDACTED] at 4:18 PM with the Registered Dietitian (RD), the RD stated the dietary staff should follow the pureed recipes when preparing pureed food because following the recipe could ensure the food provides necessary nutrition for the resident ' s needs and ensure the food had right texture to prevent choking.

During an interview on [DATE REDACTED] at 2:40 PM with the Administrator (ADM), the ADM stated the dietary supervisor, and Registered Dietitian had mentioned the issue of the inappropriate texture of the pureed food to him more than three times in the past, but this issue had not been discussed in the QAPI and there was no written QAPI plan to address it. The ADM stated they should have discussed this issue during the QAPI and should have done something more effectively for it.

47467

2. On [DATE REDACTED] at 3:09 PM, while onsite at the facility, the California Department of Public Health (CDPH) an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was identified and called regarding the facility ' s failure to notify the physician regarding significant changes in Resident 98 ' s respiratory conditions and provide the necessary respiratory care and monitoring.

3. LVN 1 who was in charge of Resident 98 on [DATE REDACTED] to [DATE REDACTED] did not implemented Resident 98 ' s Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident ' s preferences.

During an interview on [DATE REDACTED] at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 98 from 11 PM on [DATE REDACTED] until the resident expired on [DATE REDACTED] at 5:59 AM. LVN 1 stated, Resident 98 was alert, oriented and responsive at the beginning of his shift on [DATE REDACTED], with oxygen saturation above 90% while receiving oxygen supplement at 3 LPM. LVN 1 stated around 5:30 AM, CNA 1 told him Resident 98 had a change in condition and breathing very slow and was very weak. LVN 1 stated he went to Resident 98's room, and Resident 98 opened his eyes but was very weak. LVN 1 stated he checked Resident 98's vital signs a few times but could not recall the results of the VS and he did not document the vital signs in Resident 98's clinical record. LVN 1 stated, he did not report Resident 98's change of condition to the Registered Nurse (RN) who was working during his shift on [DATE REDACTED]. LVN 1 stated, he did not increase Resident 98's oxygen level as per physician's order because the resident had diagnosis of COPD. LVN 1 stated, he did not inform the physician when Resident 98's condition changed with oxygen saturation down to 88% and 70%. LVN 1 stated he informed Resident 98's physician after the resident passed away on [DATE REDACTED]. LVN 1 stated, he did not know why he did not notify Resident 98's physician, call for help or call 911 when CNA 1 reported to him that Resident 98 was weak with slow breathing and a decrease in the resident's oxygen saturation. LVN 1 stated, Resident 98 expired less than one hour after he was notified by CNA 1 for Resident 98's weakness and slow breathing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0867 A review of the death certificate of Resident 98 indicated Resident 98 expired at the facility on [DATE REDACTED] with

the cause of death as cardiac dysrhythmia (abnormal or irregular heartbeat), acute respiratory distress and Level of Harm - Minimal harm or pulmonary hypertension. potential for actual harm

During an interview on [DATE REDACTED] at 9:40 AM with the Director of Nursing (DON) stated, she did not investigate Residents Affected - Some the possible cause of death of Resident 98 on [DATE REDACTED]. The DON stated, after she was made aware of the incident by the surveyor, she then proceeded to investigate and interviewed Licensed Vocation Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1, who took care of Resident 98 on [DATE REDACTED] from 11 PM until the resident expired on [DATE REDACTED] at 5:59 AM, to identify possible cause of death and determine if the staffs implemented preventive actions per facility ' s policy and procedures.

During an interview on [DATE REDACTED] at 3:10 PM with the Administrator (ADM), the ADM stated, he should be made aware of any type of adverse event in the facility. The ADM stated, he was not informed about Resident 98 ' s death. The ADM stated, the DON was supposed to be in charge of the daily census and the number of residents that expired or transferred to the hospital daily. The ADM stated, due to the lack of oversight from

the DON, the incident was not identified as an adverse event and was not brought to his attention. The ADM stated, Resident 98 ' s death should had been identified with possible causes and determine if there was a written plan that should have been created and implemented when Resident 98 expired on [DATE REDACTED].

During a review of the facility ' s policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI, a data-driven approach to improve the quality of care and services in healthcare settings), revised [DATE REDACTED], the P&P indicated the following:

-It is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and address all the care and unique services the facility provides.

-The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events.

-The facility maintains procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. The facility draws data from multiple sources, which may include but not limited to: incident/accident reports, including reports of adverse events, paper and electric medical records, medical

record audits.

-Department heads are responsible for ensuring data is collected appropriately and performance metrics are monitored in accordance with facility policy. Sample data collection forms are maintained with the written QAPI plan.

-Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event. An investigation will be conducted on each identified medical error or adverse event to analyze cause. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and educations. Monitoring will be conducted to ensure desired outcomes are achieved and sustained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary environment for six out of 20 sampled residents(Residents in room [ROOM NUMBER] and 5) when a rusty and dirty commode was found in shared bathroom of room [ROOM NUMBER] and 5.

This failure resulted in unsanitary environment and potential to lower the residents' quality of life.

Findings:

During an observation on 3/25/2025 at 9:52 AM in the shared the restroom between room [ROOM NUMBER] and 5, a dirty and rusty commode was observed.

During an interview on 3/25/2025 at 10 AM with Housekeeper (HK) 1, HK 1 stated, she was not aware and did not receive any report that the commode was dirty and rusty. HK 1 stated, HK 1 supposed to check all equipment and report to the Maintenance Supervisor (MS) to replace dirty and rusty commode. HK 1 stated,

she could not recall if she checked shared restrooms between room [ROOM NUMBER] and 5 to make sure all equipment was clean and functional.

During a concurrent observation and interview on 3/25/2025 at 10:10 AM with the MS in the shared restroom between room [ROOM NUMBER] and 5, a dirty and rusty commode was observed. The MS stated, the commode was shared by all six residents residing in room [ROOM NUMBER] and 5. The MS stated, by the appearance of the commode, it should have been dirty and rusty for at least a few days. The MS stated, he was responsible to make sure all the facility ' s equipment were sanitary, clean, and functional. The MS stated, he would replace a new commode right away.

During a review of the facility ' s policy and procedure (P&P) titled, Safe and Homelike Environment, revised 12/19/2022, the P&P indicated, sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living.

During a review of the facility ' s P&P titled, Preventative Maintenance Program, revised 12/19/2022, the P&P indicated, a preventative maintenance program shall be developed and implemented to ensure the provision of safe, sanitary, and comfortable environment for residents, staff, and the public. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 055989

F-F760.

Findings:

During a review of Resident 52's Admission Record (Face Sheet), indicated the facility admitted the resident

on 9/5/2022 and readmitted on [DATE REDACTED] with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and HTN.

During a review of Resident 52 ' s History and Physical (H&P), dated 12/24/2024 indicated, Resident 52 does not have the mental capacity to make medical decisions.

During a review of Resident 52's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/16/2025, indicated the resident ' s cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and was dependent on staff for the activities of daily living.

During a review of Resident 52's Order Summary, dated 3/27/2025, the Order Summary Report indicated to administer the following medications to the resident:

a. Amlodipine Besytate Oral tablet 10mg (milligram) give one table by mouth in the morning for HTN hold for systolic blood pressure (SBP - the amount of pressure in the arteries during contraction of the heart muscle) <110 or HR (hear rate) <60 with a Start date 1/13/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0759 b. Metoprolol Tartrate Oral Tablet 50 mg (Metoprolol Tartrate) Give 1 tablet by mouth three times a day for Hypertension (Hold if SBP <110 or HR <60 / Administered with food) with a Start date 2/1/2025 Level of Harm - Minimal harm or potential for actual harm c. Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM (diabetes) administer with food. Residents Affected - Few

During a medication pass observation and concurrent interview with the LVN 2 on 3/27/2025 at 9:26AM, LVN 2 prepared the medications Amlodipine and Metoprolol and checked the Resident 52 ' s blood pressure but

she did not check the resident ' s heart rate as indicated by the physician ' s order. As the LVN 2 was about to administer the Amlodipine and Metoprolol, the surveyor asked, What is the resident ' s heart rate? LVN 2 paused and stated that she forgot to check Resident 52's HR. LVN 2 then checked the resident ' s heart rate, which was 65 bpm (beats per minute), before proceeding with administration.

During an interview on 3/27/2025 at 9:26AM, LVN 2 stated she forgot to check Resident 52's heart rate. LVN 2 checked the resident's heart rate, then proceeded to administer metoprolol tartrate since Resident 26's heart rate was 65 beats per minute. LVN 2 she acknowledged the error of not providing food during medication administration.

During an interview on 3/28/2025 at 1:50 PM, with the Director of Nurses (DON stated, Heart rate must be checked before administering medications like Metoprolol and Amlodipine because it can lower the heart rate. If a resident ' s heart rate is already low, giving the medication can be harmful and may cause serious complications, including dizziness, falls, or even more severe cardiac issues. DON stated nurse need to provide food to residents if there is an ordered to give.

During a review of the facility's policy and procedure (P&P) titled, Medications Administration, revised 2022, indicated to:

Obtain and record vital signs when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician ' s prescribed parameters.

Administered medication as ordered in accordance with manufacture specification.

Provide appropriate amount of food and fluid.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50012 potential for actual harm Based on interview and record review the facility failed to ensure one out of four residents (Resident 52) was Residents Affected - Few free from significant medication errors as indicated in the physician ' s order, pharmacy recommendation and facility's policy and procedures by failing to ensure Licensed Vocational Nurse (LVN) 2 failed to check the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication given to lower the blood pressure) and Amlodipine (medication ordered to manage Resident 52's hypertension [HTN - elevated blood pressure]).

This failure places the resident at risk for adverse effects, including bradycardia (low heart rate), hypotension (low blood pressure), dizziness, increasing the risk of falls, and cause the heart to stop that could lead to hospitalization or death.

Findings:

During a review of Resident 52's Admission Record (Face Sheet), indicated the facility admitted the resident

on 9/5/2022 and readmitted on [DATE REDACTED] with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (HTN-a long-term medical condition in which the blood pressure in the arteries is persistently elevated).

During a review of Resident 52's History and Physical (H&P), dated 12/24/2024 indicated, Resident 52 does not have the mental capacity to make medical decisions.

During a review of Resident 52's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/16/2025, indicated the resident ' s cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and was dependent on staff for the activities of daily living.

During a review of Resident 52's Order Summary, dated 3/27/2025, the Order Summary Report indicated to administer the following medications to the resident:

a. Amlodipine Besytate Oral tablet 10mg (milligram) Give one table by mouth in the morning for HTN hold for systolic blood pressure (SBP - the amount of pressure in the arteries during contraction of the heart muscle) < (less than)110 or HR (hear rate) <60 with a start date 1/13/2025.

b. Metoprolol Tartrate Oral Tablet 50 mg (Metoprolol Tartrate) Give 1 tablet by mouth three times a day for Hypertension (Hold if SBP <110 or HR <60 / administered with food) with a start date 2/1/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0760 During a medication pass observation and concurrent interview with the LVN 2 on 3/27/2025 at 9:26AM, LVN 2 prepared the medications Amlodipine and Metoprolol and checked the Resident 52 ' s blood pressure but Level of Harm - Minimal harm or she did not check the resident ' s heart rate as required by the physician ' s order. As the LVN 2 was about to potential for actual harm administer the Amlodipine and Metoprolol, the surveyor asked, What is the resident ' s heart rate? The LVN 2 paused and stated that she forgot to check Resident 52's HR. LVN 2 then checked the resident ' s heart Residents Affected - Few rate, which was 65 bpm (beats per minute), before proceeding with administration.

During an interview on 3/27/2025 at 9:26AM, LVN 2 stated she forgot to check Resident 52's heart rate. LVN 2 checked the resident's heart rate, then proceeded to administer metoprolol tartrate since Resident 52s heart rate was 65 beats per minute.

During an interview on 3/27/2025 at 1:50 PM, with the Director of Nurses (DON stated, Heart rate must be checked before administering medications like Metoprolol and Amlodipine because the medication can lower

the heart rate. If a resident ' s heart rate is already low, giving the medication can be harmful and may cause serious complications, including dizziness, falls, or even more severe cardiac (heart) issues.

During a review of the facility's policy and procedure (P&P) titled, Medications Administration, revised 2022, indicated to obtain and record vital signs when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician ' s prescribed parameters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 46779

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure the two of two dietary staff (Dietary Manager and Facility Cook) had appropriate competencies and skills sets to carry out the functions of the food and nutrition service based on resident assessments, individual plans of care of the 30 residents who were prescribed with pureed diet (diet with food that has been blended, mashed, or strained until it's smooth and free of lumps, like applesauce or mashed potatoes, often used for those with difficulty chewing or swallowing) and were served pureed food that was pasty and thick in texture by failing to:

1. Ensure the Facility [NAME] reviewed and followed the recipe to ensure adequate measurement of thickener powder (powder like starch used to thicken the texture of food) were mixed when preparing the pureed food on 3/26/2025.

2. Ensure the Dietary Manager follow the pureed recipe and oversee the Facility [NAME] when preparing puree food for the residents on 3/26/2025.

The deficient practices had put the residents at risk poor nutrition to weigh loss or gain, and risk of chocking and aspiration (food enters the airway and affecting air exchange in the body) that could result in aspiration pneumonia (severe infection of the lungs) and/or death.

Findings:

During an observation on 3/26/2025 at 10:46 AM in the kitchen, to prepare for puree chicken, the Facility [NAME] mixed unmeasured amount of chopped chicken, chicken flavor gravy powder, and water into a blender, then grinded the mixture.

During an observation on 3/26/2025 at 10:49 AM in the kitchen, the Facility [NAME] poured the grinded chicken into a stainless-steel steam pan and scooped the thickener power that was less than a full scoop and mixed the thickener power in the grinded chicken. Next, the Facility [NAME] put grinded chicken inside

the oven to keep it warm. The recipe for the pureed chicken was not present and the Facility [NAME] did not

review and follow the recipe for pureed chicken to ensure adequate measurement of thickened powder were mixed during the cooking process.

During an observation on 3/26/2025 at 11:10 AM in the kitchen, to prepare for puree noodle, the Facility [NAME] filled the unmeasured amount of cooked noodle and water into the blender and grinded the mixture.

During an observation on 3/26/2025 at 11:12 AM in the kitchen, the Facility [NAME] poured the grinded noodle into a stainless-steel steam pan then used a cooking spoon to scoop the thickener powder four times without checking the recipe and added with the grinded noodle. The recipe for the pureed noodle was not present and the cook did not review and follow the recipe for pureed noodle during the cooking process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0802 During an observation on 3/26/2025 at 11:24 AM in the kitchen, the Facility [NAME] poured the unmeasured amount of grinded vegetable into a stainless-steel steam pan. Then, the Facility [NAME] scooped the Level of Harm - Minimal harm or thickener powder three times without checking the recipe and added to the grinded vegetable. The recipe for potential for actual harm the pureed vegetable was not present and the cook did not check and follow the recipe for pureed vegetable

during the cooking process. Residents Affected - Some

During an observation and interview on 3/26/2025 at 11:28 AM with the Dietary Manager (DM) in the kitchen,

the DM filled the blender and grinded unmeasured amount of regular rice porridge. The DM did not add any thickener power into the grinded porridge. The DM stated the grinded porridge was for the facility's residents

on pureed diet.

During an observation on 3/26/2025 at 11:34 AM in the kitchen, the Dietary Aid (DA) grinded some chocolate cookies in the blender, then, she lifted the thickener container and poured an unmeasured amount of the thickener powder into the blender two times. Next, the DA grinded the cookies with thickener power again.

During a concurrent observation and interview on 3/26/2025 at 1:10 PM with the DM, the consistency of the test tray's pureed chicken and noodle was pasty. The DM performed the spoon tilt test (a test used to a spoon to test the texture of food to ensure it is safe and easy to swallow) on the test tray's pureed chicken and noodle to determine if the texture of the pureed food was appropriate. The DM stated the pureed chicken and noodle were too sticky and did not slide off the spoon when tilted, so the textures of the pureed chicken and noodle were not consistent with pureed texture. The DM stated the dietary staff supposed to measure how much the thickener power was put into the pureed food when preparing them. The DM stated someone was supposed to check the final products to make sure texture of the food was correct, but she was not sure which dietary staff was the one in charge of checking the final product before the tray line and they did not have log of checking the textures of the food.

During an interview on 3/26/2025 at 2:11 PM with the Facility [NAME] stated, she did not follow the pureed recipes and did not know if they had the pureed recipes available. The [NAME] stated she added the thickener powder by eyeballing the amount of thickener needed, instead of measure it, when preparing pureed food. The [NAME] stated she would taste the pureed food and based on her experience to determine if the texture of the pureed food was right.

During an interview on 3/26/2025 at 4:18 PM with the Registered Dietitian (RD), the RD stated the dietary staff should follow the pureed recipes when preparing pureed food because following the recipe could ensure

the food provides necessary nutrition for the resident ' s needs and ensure the food had right texture to prevent choking.

During a review of the facility's Recipe for Pureed Fish/Meat/Poultry, dated 3/27/2025, the recipe indicated for 35 servings, the ingredients included cooked meat product six and half pounds (lb, a measurement unit for weight) and one ounce (oz, a measurement unit), reserved cooking liquid or broth one quarter (qt, a measurement unit) and food thickener three tablespoons (tbsp, a measurement unit) and one and half teaspoon (tsp, a measurement unit). The recipe also indicated add thickener with one and half tsp and add more gradually until desired texture is achieved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0802 During a review of the facility's Recipe for Pureed Vegetables, dated 3/27/2025, the recipe indicated for 35 servings, the ingredient included cooked, drained and seasoned vegetables one gallon (gal, a measurement Level of Harm - Minimal harm or unit) and one and half cup and food thickener three tbsp and one and half tsp. The recipe also indicated add potential for actual harm thickener with one and half tsp and add more gradually until desired texture is achieved.

Residents Affected - Some During a review of the facility's Recipe for Pureed Desserts, dated 3/27/2025, the recipe indicated for 35 servings, the ingredients included 35 regular portion of desserts, apple juice or two percent milk three and half cups, and food thickener three tbsp and one and half tsp. The recipe also indicated add thickener with one and half tsp and add more gradually until desired texture is achieved. The recipe also indicated add thickener with one and half tsp and add more gradually until desired texture is achieved.

During a review of the facility's Recipe for Pureed Potatoes, Pasta, [NAME] and other Grains, dated 3/27/2025, indicated for 35 servings, the ingredients included cooked and drained potatoes, pasta or rice one gal and one and half cups, broth or two percent milk two qt and third of fourth cup, margarine one third of a cup and one and two third of a tbsp, and food thickener three tbsp and one and half tsp.

During a review of the facility's policy and procedure (P&P), titled Pureed Food Preparation, dated 12/19/2022, the P&P indicated to Follow the recipes and spreadsheets for pureed food items.

During a review of the facility's P&P, titled Therapeutic Diet Orders, dated 12/19/2022, the P&P indicated Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive contents as prescribed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of two sampled residents (Resident 47) who had difficulty swallowing was served pureed diet (a food item that has been blended, mixed, or processed into a smooth and uniform texture) that was too thick in texture.

This deficient practice resulted in Resident 47 and other residents with difficulty swallowing to be at increased risk for choking (happens when something blocks the airway, preventing a person from breathing properly, often due to food or other objects getting stuck in the throat) and aspiration (accidentally inhaling food, liquid, or other material into the lungs instead of the stomach, which can lead to complications like pneumonia [a severe lung infection]) that could lead to death.

Finings:

During a review of Resident 47's Admission Record (AR), the AR indicated the facility admitted Resident 47

on 10/3/2019 and readmitted on [DATE REDACTED] with diagnoses that included dysphagia (difficulty in swallowing) following cerebral infarction (or ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), pneumonia, and dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities].

During a review of Resident 47's History and Physical (H&P), dated 7/24/2024, indicated Resident 47 did not have the capacity to understand and make decision. The H&P indicated, Resident 47 had diagnosis that included Covid pneumonia, dementia, and was a potential for rehabilitation due to aspiration prevention.

During a review of Resident 47's Minimal Data Set (MDS-a federally mandated resident assessment), dated 10/10/2024, indicated Resident 47 ' s cognition (ability to think, remember, and reason with no difficulty) was severely impaired and needed moderate assistance (helper does less than half the effort) in eating and oral hygiene.

During a review of Resident 47's Order Summary Report, indicated Resident 47 had a physician order on 2/2/2025 for regular diet with puree texture and thin consistency (flows easily and is not thick).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0805 During a review of Resident 47's Speech Therapy - SLP Evaluation (Speech-Language Pathologist comprehensive assessment to determine if a person has swallowing disorders, or feeding disorders) and Level of Harm - Minimal harm or Plan of Treatment, for the period of 1/26/2025 - 2/22/2025, indicated Resident 47 needed maximal potential for actual harm assistance in feeding and had difficulty in initiating oral stage (a preparatory phase which includes suckling, chewing, breaking down food, mixing the food with saliva; and the formation of a bolus [chewed food] of Residents Affected - Few suitable size and consistency), oral residue (food or liquid remaining in the mouth after swallowing) and residue were on palate (the roof of the mouth) and/or tongue with clearance attempts. The evaluation indicated Resident 47 had impaired pharyngeal phase [the rapid stage where the food bolus is propelled from the back of the mouth into the esophagus (a tube that connects the mouth to the stomach)] as evidenced by reflexive throat clearing (involuntary action, like a cough, to clear the throat, often triggered by

a sensation of something stuck or irritating in the throat) after intake. The evaluation indicated Resident 47 was at risk for aspiration and the recommendation was aspiration precautions with close supervision during oral feeding, and regular diet with moist puree consistencies.

During a review of Resident 47's Nutritional Assessment, dated 3/11/2025, indicated Resident 47 had diet order for regular diet with pureed texture and thin liquid consistency. The assessment indicated Resident 47's risk factors were difficulty in swallowing, coughing or choking during meals, and complaints of difficulty or pain when swallowing.

During a review of Resident 47's care plan, dated 3/19/2025, indicated Resident 47 had a potential for choking, aspiration, weight loss, poor intake related dysphagia manifested by impaired chewing/swallowing.

The care plan indicated the goal was that Resident 47 would be able to chew food and tolerate oral intake without difficulty and the interventions included to provide alter diet consistency to accommodate the resident ' s chewing ability, assist during meals times, and provide diet as ordered.

During a concurrent observation and interview on 3/25/2025 at 12:30 PM with Resident 47's Family Member (FM) 1 in the resident's room, FM 1 assisting Resident 47 to eat food brought from home with no facility staff present, a facility's lunch tray was observed at Resident 47's bedside. FM 1 stated, she had been preparing food for Resident 47 and fed him every day for a year because the facility's puree food was too thick, and Resident 47 would gag and cough out if she tried to feed him the facility's food because the food would get stuck in his mouth.

During a concurrent observation and interview on 3/25/2025 at 12:45 PM with Resident 47's FM 1 in the resident's room, FM 1 showed the surveyor Resident 47's lunch tray which was brought in by the facility. FM 1 stated, she did not know what was prepared by the facility. FM 1 stated, there was a portion of white puree food that looked like puree rice to her. FM 1 the food was sticking to the spoon without able to slide down and there were still lumps in the remaining white food. FM 1 then fed Resident 47. Resident 47 was observed chewing and constantly coughed out the spoonful of food when trying to swallow it.

During an interview on 3/25/2025 at 12:55 PM with Certified Nurse Assistant (CNA) 2, CNA 2 stated, he had been working in the past 9 months and had been seeing Resident 47's family members brought in food to feed Resident 47 during breakfast, lunch and dinner every day.

During an observation on 3/26/2025 at 12:55 PM with Resident 47's FM 1 in the resident's room, FM 1 was feeding Resident 47 with homemade food, no staffs was present in the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0805 During a concurrent observation and interview on 3/26/2025 at 1:05 PM with the Dietary Manager (DM) in Resident 47's room, Resident 47's lunch tray was observed while FM 1 was feeding Resident 47 with Level of Harm - Minimal harm or homemade food. The DM stated, based on their menu, Resident 47's lunch tray should have puree chicken, potential for actual harm puree noodles and puree blended vegetables. The DM demonstrated a spoon test for puree consistency on Resident 47's lunch tray brought by the facility and stated that the consistency did not pass the test because Residents Affected - Few the food should be thinner. The DM stated, Resident 47's food was too thick and was not in the correct consistency, which could create a potential that food could get stuck in the resident's mouth and potentially increase risk of choking.

During an interview on 3/26/2025 at 2:43 PM with the facility's cook (Cook) in the kitchen, the [NAME] stated,

she did not review and follow the facility's recipe when preparing for puree food. The [NAME] stated, she was trained by the previous DM and remembered how to make puree food. The [NAME] stated, after she completed making puree food, she would taste it and based on her experience, if the taste seemed like the right texture for her, the food was ready to be served.

During an interview on 3/26/2025 at 4:32 PM with the facility's Registered Dietician (RD), the RD stated, it was very important that the [NAME] must always follow the facility's recipe when making puree food for the correct texture and consistency. The RD stated, due to risk of aspiration and choking, Resident 47 should always be provided with the correct diet texture and consistency.

During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, dated 12/19/2022, indicated the facility provides all residents with foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Therapeutic diets will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations but not limited to: swallowing difficulty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 46779

Residents Affected - Some Based on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling in accordance with the facility ' s policy and procedures by failing to ensure:

1. The scoop used for scooping flour was not on the top of the flour container and was stored in a plastic bag when not in use to limit exposure to potential contamination.

2. The dietary staff correctly conduct the calibration (correlating the readings of an instrument with those of a standard to check the instrument's accuracy) of the food thermometer used to readily identify the proper temperatures of the food being served.

These deficient practices had the potential to result in cross contamination and food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization . and put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Findings:

1. During a concurrent observation and interview on 3/25/2025 at 8:32 AM with the Dietary Manager (DM), in

the kitchen dry storage room, a scoop with the white powdery residue was on the top of the flour container that was not placed in a plastic bag. The DM stated the scoop should be placed in a plastic bag to prevent potential contamination to the scoop and the flour that would be used for cooking for the residents. The DM stated the dietary staff who used last probably forgot to put the scoop back into the plastic bag this morning.

2. During a concurrent observation and interview on 3/26/2025 at 9:30 AM with the DM, the DM prepared a cup of ice water and submerged a digital thermometer ' s sensing area in the ice water. The DM removed the digital thermometer out of the ice water after the display screen read 39-degree Fahrenheit (a measurement unit for temperature). The DM stated the thermometer was calibrated as long as the thermometer reading was below 40-degree Fahrenheit. The DM stated this thermometer was used for checking the hot and cold food that were served to the residents.

During an interview on 3/26/2025 at 9:35 AM with the DMA, the DMA stated the digital thermometer which was used to check the temperature of hot and cold food should be calibrated in the ice water and the reading should read 32-degrees Fahrenheit. The DMA stated the DM did not calibrate the thermometer correctly and could lead to inaccurate temperature measurement for the food that were served to the residents, and cause food poisoning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0812 During a review of the facility ' s policy and procedure (P&P), titled Food Safety and Food Storage, revised

on 11/4/2024, the P&P indicated Foods and beverages shall be distributed and served to residents in a Level of Harm - Minimal harm or manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone, potential for actual harm and All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Residents Affected - Some

During a review of the facility ' s P&P, titled Calibrating Thermometers, dated 12/19/2022, the P&P indicated Dietary employees will use either the ice-point method . calibrate and verify the accuracy of food thermometers and To use the ice-point method: a. Prepare a 50/50 ice and water mixture. b. Submerge the sensor/probe of the thermometer a minimum of 2 inches into the solution until the needle stops moving and temperature has stabilized, about 30 seconds. c. Temperature measurement should be 32 Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46779

Residents Affected - Some Based on interview and record review, the QAPI committee (Quality Assurance and Performance Improvement committed are group of facility staff uses data-driven approach to improve the quality of care and services in healthcare settings) facility failed to systematically identify investigate, analyze and use data and information relating to monitoring and preventing adverse events ( an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof) in the facility by collecting data and input from direct staffs, residents and responsible parties in accordance with the facility ' s policy and procedure by failing ensure:

1. A system in place to Identify, address and develop a written plan to ensure the dietary staff following the pureed food (food that has been blended, mashed, or strained until it's smooth and free of lumps, like applesauce or mashed potatoes, often used for those with difficulty chewing or swallowing) recipes when preparing pureed food for 30 residents of 30 residents who were prescribed with pureed diet.

2. A system in place to identify and investigate any possible adverse event of the possible or actual cause of one of one sampled resident (Resident 98) who expired from respiratory distress related to COPD, pulmonary hypertension.

3. A system in place to ensure determine that Resident 98 ' s POLST was implemented according to the resident ' s preference of end-of-life treatments.

These deficient practices placed the residents at risk for adverse events including deaths that could have been prevented. In addition, the deficient practice had put the residents at risk poor nutrition to weigh loss or gain, and risk of chocking and aspiration (food enters the airway and affecting air exchange in the body) that could result in pneumonia (severe infection of the lungs) and/or death.

Cross Reference to

F-F867.

Findings:

During a review of Resident 98's Admission Record (AR), the AR indicated the facility admitted Resident 98

on [DATE REDACTED] with diagnoses that included acute respiratory failure with hypoxia, COPD with exacerbation (worsened symptoms), pulmonary hypertension, type 2 diabetes mellitus with hyperglycemia (DM, a chronic condition that happens when the body has persistently high blood sugar levels), and atrial fibrillation (afib a common type of irregular heartbeat).

During a review of Resident 98's Order Summary Report (OSR), indicated on [DATE REDACTED], Resident 98 had a physician order to monitor temperature and oxygen saturation every shift for suspected/confirmed Covid-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus), and to call the physician if oxygen saturation is newly below 91%, or if the resident's usual oxygen saturation is lower or is 3% or more lower than their baseline.

During a review of Resident 98's Care plan (CP), dated [DATE REDACTED], indicated Resident 98 had COPD exacerbation. The goal was that the Resident 98 would display optimal breathing patterns (a respiratory rate of 12 to 20 breaths per minute with regular, rhythmic inhalations and exhalations) daily with the interventions that included monitoring for signs and symptoms of acute respiratory insufficiency such as shortness of breath at rest, cyanosis (a bluish or purplish discoloration of the skin, typically caused by a lack of oxygen in

the blood), and somnolence (lethargy, weakness, and difficulty thinking), and to administer oxygen via NC at , d+[DATE REDACTED] LPM continuously, may titrate oxygen to ,d+[DATE REDACTED] LPM via mask to maintain oxygen saturation greater or equal to 94%.

During a review of Resident 98's CP, dated [DATE REDACTED], indicated Resident 98 was at risk for Covid-19 related to diagnosis of COPD exacerbation, DM, and afib. The interventions included to follow Resident 98's POLST, monitor temperature and pulse oximetry (a test used to measure oxygen levels of the blood) per physician's order and report abnormal findings to the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0695 During a review of Resident 98's CP, dated [DATE REDACTED], indicated Resident 98 had altered cardiovascular (related to heart and blood vessels) status related to afib, hypertension (high BP), and hyperlipidemia (high Level of Harm - Immediate level of fats in the bloodstream). The interventions included to monitor Resident 98's vital signs and notify the jeopardy to resident health or physician of significant abnormalities, monitor/document/report to the physician for changes in capillary refill safety (a quick test to assess blood flow to tissues by observing how quickly color returns to the nail bed after pressure is applied) and color/warmth of extremities. Residents Affected - Few

During a review of Resident 98's History and Physical, dated [DATE REDACTED], indicated Resident 98 had the capacity to understand and make decision.

During a review of Resident 98's OSR, indicated on [DATE REDACTED], for Resident 98 to receive oxygen via NC at , d+[DATE REDACTED] LPM continuously, may titrate oxygen to ,d+[DATE REDACTED] LPM via mask to maintain oxygen saturation greater or equal to 94%.

During a review of Resident 98's OSR, indicated on [DATE REDACTED], the physician ordered to follow the instructions

in Resident 98's POLST.

During a review of Resident 98's POLST, dated [DATE REDACTED], indicated if Resident 98 was found with a pulse and/or is breathing, the healthcare provider may, in addition oxygen treatment, use a non-invasive positive airway pressure (a method of breathing support that delivers pressurized air or oxygen through a mask without inserting a tube into the windpipe) which included continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open), bi-level positive airway pressure (BiPAP, a type of device that helps with breathing), and bag valve mask (a handheld device used to provide emergency breaths to someone who is not breathing or not breathing adequately) assisted respirations.

During a review of Resident 98's Minimal Data Set (MDS-a federally mandated resident assessment), dated [DATE REDACTED], indicated Resident 98's cognition (ability to think, remember, and reason) was moderately impaired and needed moderate assistance (helper does less than half the effort) in eating and oral hygiene.

During a review of Resident 98's Weights and Vitals Summary, indicated Resident 98's last vital signs was taken on [DATE REDACTED] at 1:09 AM with the resident's BP at ,d+[DATE REDACTED] mmHg (millimeters of mercury, a unit of measurement for pressure), oxygen saturation of 93% while the resident was on room air, heart rate at 100 beats per minute, and temperature of 98.7 degrees Fahrenheit (a scale for measuring temperature). There was also no documented evidence that Resident 98 was monitored for vital signs on [DATE REDACTED] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, and had slow breathing.

During a review of Resident 98's Progress Notes, dated [DATE REDACTED], indicated at 5:50 AM during CNA morning care, Resident 98 responded only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC until the resident passed away. There was no documented evidence in the report that Resident 98 was provided with increased oxygen level to increase oxygen saturation to 94% as ordered by the physician. There was also no documented evidence that Resident 98 was monitored for vital signs, provided with ,d+[DATE REDACTED] LPM oxygen via mask per physician's order on [DATE REDACTED] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, had slow breathing, and oxygen saturation at 70 % while on 3 LPM oxygen via NC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0695 During a review of Resident 98's SBAR Communication Form (a structured approach to healthcare communication, standing for Situation, Background, Assessment, and Recommendation to ensure clear and Level of Harm - Immediate concise information exchange, especially in critical situations) and clinical records on [DATE REDACTED], indicated that jeopardy to resident health or there was no documented evidence that the physician was notified when Resident 98's condition changed by safety responding only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC on [DATE REDACTED] at 5:50 AM until the resident expired on [DATE REDACTED] at 5:59 AM. Residents Affected - Few

During a review of Resident 98's Record of Death, dated [DATE REDACTED], indicated Resident 98 expired on [DATE REDACTED] at 5:59 AM with the final diagnosis that included COPD, hypoxia and respiratory failure.

During a review of Resident 98's Physician's Discharge Summary, dated [DATE REDACTED], indicated Resident 98 was admitted on [DATE REDACTED] and was discharged from the facility due to resident expired on [DATE REDACTED] at 5:59 AM.

During a review of Resident 98's Death Certificate dated [DATE REDACTED], indicated Resident 98 expired on [DATE REDACTED] with the primary cause of death as cardiac dysrhythmia and secondary cause of death that included acute respiratory distress and pulmonary hypertension.

During an interview on [DATE REDACTED] at 6:38 AM with CNA 1, CNA 1 stated, he took care of Resident 98 from 11 PM on [DATE REDACTED] until the resident expired on the morning of [DATE REDACTED]. CNA 1 stated, when he was caring for Resident 98 at the beginning of his shift, Resident 98 was alert and oriented, with the vital signs including BP and oxygen saturation was within normal limits, though he could not recall the results of the vital signs and time they were taken. CNA 1 stated, around ,d+[DATE REDACTED]:30 AM during his rounds in the facility, he noticed that Resident 98 did not respond when he called Resident 98's name, and breathing very slow but his skin was warm when touched and the resident was very weak with his oxygen level at around 88%. CNA 1 stated, he immediately reported to LVN 1 that Resident 98's oxygen blood level was low and then LVN 1 went to assess Resident 98. CNA 1 stated, they (LVN 1 and CNA 1) checked Resident 98's vital signs about four times, but he could not recall the results and time the vital signs were taken. CNA 1 stated, he could only recall that Resident 98's oxygen level was at 88% when he first found the resident around ,d+[DATE REDACTED]:30 AM and notified LVN 1. CNA 1 then stated Resident 98 slowly died in about 1 hour while receiving oxygen via NC.

During a concurrent record review and interview on [DATE REDACTED] at 6:52 AM with LVN 1, Resident 98's Weights and Vitals Summary, SBAR Communication Form, and clinical records on [DATE REDACTED] and [DATE REDACTED] were reviewed. LVN 1 stated, there was no records indicating Resident 98 was assessed and monitored for vital signs, Resident 98's physician was notified, or interventions were provided related to Resident 98's slow breathing with oxygen saturation at 70% on [DATE REDACTED] at 5:50 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0695 During an interview on [DATE REDACTED] at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 98 from 11 PM on [DATE REDACTED] until the resident expired on [DATE REDACTED] at 5:59 AM. LVN 1 stated, Resident Level of Harm - Immediate 98 was alert, oriented and responsive at the beginning of his shift on [DATE REDACTED], with oxygen saturation above jeopardy to resident health or 90% while receiving oxygen supplement at 3 LPM. LVN 1 stated, Resident 98 was able to make his needs safety known. LVN 1 stated, when LVN 1 provided Resident 98 with his scheduled breathing treatment (treatment to prevent difficulty breathing and shortness of breath) at 4 AM, Resident 98's oxygen saturation was about Residents Affected - Few 93% and Resident 98 was placed back on ,d+[DATE REDACTED] LPM oxygen via NC after the breathing treatment. LVN 1 stated around 5:30 AM, CNA 1 told him Resident 98 had a change in condition and breathing very slow and was very weak. LVN 1 stated he went to Resident 98's room, and Resident 98 opened his eyes but was very weak. LVN 1 stated he checked Resident 98's vital signs a few times but could not recall the results of

the VS and he did not document the vital signs in Resident 98's clinical record. LVN 1 stated, he did not report Resident 98's change of condition to the Registered Nurse (RN) who was working during his shift on [DATE REDACTED]. LVN 1 stated, he did not increase Resident 98's oxygen level as per physician's order because the resident had diagnosis of COPD. LVN 1 stated, he did not inform the physician when Resident 98's condition changed with oxygen saturation down to 88% and 70%. LVN 1 stated he informed Resident 98's physician

after the resident passed away on [DATE REDACTED]. LVN 1 stated, he supposed to notify Resident 98's physician, call for help or call 911 when CNA 1 reported to him that Resident 98 was weak with slow breathing and a decrease in the resident's oxygen saturation. LVN 1 stated, Resident 98 expired less than one hour after he was notified by CNA 1 for Resident 98's weakness and slow breathing.

During a review of LVN 1's statement provided by the facility, dated [DATE REDACTED] not timed, indicated on [DATE REDACTED] at 11 PM, Resident 98 was laying comfortably in bed with oxygen via delivered via NC at 3 LPM with no sign and symptoms of respiratory distress. The statement indicated on [DATE REDACTED] at 4 AM, LVN 1 administered the routine breathing treatment, Resident 98 was sleepy in bed, then at 5:50 AM, CNA 1 called LVN 1's attention and informed him that Resident 98 was only responding by opening his eyes. The statement indicated LVN 1 checked Resident 98's oxygen saturation that was 70 %. While Resident 98 was receiving oxygen supplement at 3 LPM. The statement indicated, LVN 1 elevated the Resident 98's head of the bed then suddenly Resident 98 became weak and unresponsive, like the resident last breath.

During a review of CNA 1's statement provided by the facility, dated [DATE REDACTED] not timed, indicated on [DATE REDACTED] at 5:30 AM, CNA 1 came to change Resident 98's diaper and noticed a change in his condition and immediately reported his findings to LVN 1. The statement indicated, Resident 98's oxygen saturation was at 89%, then went down to 88%, and suddenly dropped down to 70%. LVN 1 and CNA 1 checked Resident 98's BP which was lower than the limit, then CNA 1 and LVN 1 elevated Resident 98's head of the bed higher and the resident became unresponsive. The statement indicated, Resident 98's breathing was slowing down until his last breath.

During an interview on [DATE REDACTED] at 9:40 AM with the DON, the DON stated when CNA 1 reported to LVN 1 that Resident 98's oxygen saturation was trending down and the resident was weak, LVN 1 should have immediately assessed, monitored and documented Resident 98's vital signs in the resident's clinical record.

The DON stated, when LVN 1 found Resident 98's oxygen saturation of 70%, LVN 1 should have immediately called for help or Code Blue (an emergency code indicating a patient is experiencing a life-threatening medical emergency, typically a cardiac or respiratory arrest, requiring immediate medical attention and resuscitation efforts). followed the physician order to titrate Resident 98's oxygen therapy, followed Resident 98's POLST, called 911, and notified the physician to prevent a delay in treatments and interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0695 During an interview on [DATE REDACTED] at 1:02 PM with Resident 98's Primary Physician (PP) 1, PP 1 stated when Resident 98's oxygen saturation of ,d+[DATE REDACTED]% went down to 88%, it was a sudden drop of oxygen Level of Harm - Immediate saturation or a sudden change in condition, PP 1 stated LVN 1 was supposed to follow the physician's orders jeopardy to resident health or and notified him (PP1) right away, followed Resident 98's POLST, called 911 and notified the physician safety again. PP 1 stated, he was not notified of Resident 98's significant change in respiratory status on [DATE REDACTED]. PP 1 stated, he was notified only after Resident 98 already expired on [DATE REDACTED]. Residents Affected - Few

During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised [DATE REDACTED], indicated the following:

- Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.

- The equipment needed for oxygen administration will depend on the type of delivery system ordered. Type of delivery systems include nasal cannula, non-rebreather mask, CPAP mask, BiPAP mask.

- Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.

During a review of the facility's P&P tiled, Notification of Changes, revised [DATE REDACTED], indicated the facility consult with the resident's physician when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, which may include life-threatening conditions.

During a review of the facility's P&P titled, Medical Emergency Response, revised [DATE REDACTED], indicated the following:

- The employee who first witnesses or is first on the site of a medical emergency will initiate immediate action, basic first aid and summon for assistance.

- A nurse will assess the situation and determine the severity of the emergency, designate a staff member to announce a Code Blue (a medical emergency alert, usually indicating a person has experienced cardiac or respiratory arrest requiring immediate resuscitation efforts) if necessary, notify the physician and call 911 as needed.

- All available staff will respond to the emergency accordingly.

- The RN Supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 41 055989 Department of Health & Human Services Printed: 08/31/2025 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 055989 B. Wing 03/28/2025

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

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50012 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a medication error rate of Residents Affected - Few five percent or (5%) or less during medication pass for one of four observed residents (Residents 52) in which three (3) medication errors were identified out of 29 opportunities that yielded a cumulative error rate of 10.34 %.

The facility failed to ensure:

1. Licensed Vocational Nurse 2 (LVN 2) checked the heart rate of Resident 52 prior to the administration of Metoprolol tartrate (medication that lowers blood sugar level) and Amlodipine (medication ordered to manage hypertension [HTN - elevated blood pressure]).

2. Licensed Vocational Nurse 2 (LVN 2) provided food during medication administration of Metoprolol and Metformin HCL (medication given to lower blood sugar level) ordered by the physician.

These deficient practices had the potential to result in ineffective managed hypertension and diabetes and may cause a harmful significant drop in the heart rate, blood pressure, hypoglycemia (low blood sugar) and upset stomach for Resident 52.

Cross reference with