Heritage Manor

During a review of the facility's policy and procedure (P&P) titled, Provision of Quality of Care, revised 12/19/2022, the P&P indicated the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices, Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being, and A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan.

During a review of the facility's P&P titled, Nursing Care of the Resident with Diabetes Mellitus, revised 12/9/2025, the P&P indicated the facility to help the resident control his/her diabetes with diet, exercise, and insulin (as ordered), prevent recurrent hyperglycemia/hypoglycemia, recognize, manage, and document the treatment of complications commonly associated with diabetes.

The P&P indicated glucose monitoring as the management of individuals with DM should follow relevant protocols and guidelines, including physician to order the frequency of glucose monitoring, monitoring resident's blood sugar with accu-check.

The P&P indicated HA1C should be less than seven in a diabetic individual.

The P&P also indicated medication management of type II diabetes may include oral hypoglycemic agents (medication that can lower the blood sugar level) with or without insulin.

During a review of the facility's P&P titled, Registered Nurse-Job Description, dated 2023, the P&P indicated the RN participates in the admission of residents as required, observes for changes in residents ‘status, notifying the physician and resident's family or representative and documenting accordingly, transcribes physician orders to medical record and carries out orders as written, collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met, initiates, reviews and updates care plans as required.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Manor

610 North Garfield Avenue Monterey Park, CA 91754

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/14/2025 at 12:30 PM, MDSN 2 stated developing residents' comprehensive care plans is one of the tasks of the MDS nurses. MDSN 2 stated MDS nurses should know the facility's policy for developing comprehensive care plans, as the facility has up to 21 days upon resident's admission to develop a comprehensive care plan. MDSN 2 stated this included reviewing all the pertinent records (hospital records, active orders, Doctor's History and Physical notes). MDSN 2 stated the facility conducted yearly competency to licensed nurses to ensure staff were updated and provided reminders of the standard of practice.

During an interview on 8/14/2025 at 4:52 PM, the Director of Nursing (DON) stated and verified that MDSN 1 did not complete the annual licensed nurse competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully) and should have completed it for the year 2023 and 2024.

During a concurrent record review and interview on 8/14/2025 at 4:57 PM, the facility's Licensed Nurse Competency checklist was reviewed.

The DON verified that the care plan was one of the skills that was checked off on the list.

The DON stated completing the annual licensed competency was important to ensure the licensed nurses were up to date with knowledge, skills, and abilities to perform their roles for the residents.

The DON stated it would help the licensed nurses to effectively and safely conduct their tasks for the residents.

During a review of the facility's P&P titled, Training Requirement, revised on 12/19/2022, the P&P indicated the facility developed, implemented, and maintained an effective training program for all new and existing staff, consistent with their expected roles.

During a review of facility's P&P titled, Competency Evaluation, revised on 12/19/2022, the P&P indicated annual competency was evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.

During a review of facility's assessment dated [DATE], the facility assessment indicated in the staff training / education and competencies section, that Person-centered care was one of the topics in this section and should include but not be limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment references, end-of-life care, and advance care planning.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Manor

610 North Garfield Avenue Monterey Park, CA 91754

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited HERITAGE MANOR in MONTEREY PARK, CA for a deficiency under regulatory tag F-F0756 during a complaint investigation conducted on 2025-08-14.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of HERITAGE MANOR.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-05.