Heritage Manor

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had 21 days to complete a care plan for a resident who was newly admitted to the facility. MDSN 2 stated

the care plan was developed by the Interdisciplinary Team (IDT, a group of healthcare professionals who work together to provide comprehensive and coordinated care for residents)?and was being discussed

during IDT meetings or care conferences for the residents. MDSN 2 verified Resident 1's care plans were initiated on 7/15/2025, prior to having a care conference with the IDT members. MDSN 2 verified Resident 1's care plan for diabetes mellitus that was initiated on 7/15/2025 was inaccurate and should have been revised. MDSN 2 stated Resident 1 did not have an order of insulin or any diabetes medication on 7/15/2025. MDSN 2 stated the care plan interventions were not resident specific centered care and that it was important to reflect the current orders and appropriate interventions on the care plan for the entire team to know the specific care for Resident 1's diagnosis of diabetes mellitus. During a review of facility's policies and procedures (P&P) titled, Comprehensive Care Plans, revised on 12/9/2024, the P&P indicated to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

physician on 7/23/2025, the nurse should check the resident's regular blood sugar level and what diabetes medications Resident 1 was taking, and provide the pertinent information to the resident's physician to better manage the resident's blood sugar level, but the nurse did not notify the physician that there was no daily accu-check and diabetes medications for Resident 1 who had a diagnosis of DM and his blood sugar was high, as result, there was lack of communication and coordination between nursing staff and physician notification to ensure appropriate diabetic care and services were provided to the resident. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Minimum Data Set Nurse (MDSN, a licensed nurse who specializes in the assessment and documentation of patient health data in long-term care) 1 completed the annual licensed nurse competency for 2023 and 2024. This deficient practice caused an increased risk for improper resident assessments, inadequate documentation, and could negatively impact

the quality of care to the residents which could lead to hospitalization or death. Cross Referenced to F-F656, F-F684, F-F756 Findings: During an interview on 8/14/2025 at 10:30 AM, MDSN 1 stated she did not know the facility's policy and procedure for comprehensive care plans (a detailed, individualized document that outlines all aspects of a patient's medical, emotional, and daily living needs). 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 REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

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)

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.