Heritage Manor

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.

055989 08/14/2025

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

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.

055989 08/14/2025

Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/18/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with the ability to think and reason) for daily decision making.

The MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing and putting on/taking off footwear and personal hygiene.

The MDS indicated Resident 1 had no physician's orders for insulin and was not taking hypoglycemic medication.

During a review of Resident 1's MRR dated 7/1 - 7/28/2025, the MRR indicated a recommendation for Resident 1's gabapentin (medication to treat epilepsy [a brain disease] and nerve pain) and clarification of the medication route.

There were no other recommendations for July 2025 for Resident 1.

During a telephone interview on 8/14/2025 at 2:46 PM, the Consultant Pharmacist (CP) stated Resident 1's medications were reviewed in July, and there was no recommendation regarding any diabetes medication (metformin nor insulin).

The CP stated Resident 1's diagnosis of diabetes mellitus was not included in the list of diagnoses that was reviewed for Resident 1.

The CP verified Resident 1 received insulin medication from the previous admission to the facility and that he did not review Resident 1's hospital records when the MRR was conducted last month.

The CP stated he did not review Resident 1's laboratory results and also stated, I would only review hospital records, laboratory results, and doctor's notes if there's something that I would clarify, so it's only sometimes, not all the time.

During a follow up telephone interview on 8/14/2025 at 3:48 PM, the CP stated he did not have access to Resident 1's full diagnoses list.

The CP stated a recommendation for Resident 1's diagnosis of DM without medication or treatment would have been documented in July's MRR report if he knew that Resident 1 had a diagnosis of DM.

The CP stated he would have reviewed Resident 1's laboratory results if he knew that Resident 1 had diagnosis of DM.

During an interview on 8/14/2025 at 4:55 PM, the Director of Nursing (DON) stated the CP did not do a comprehensive MRR for Resident 1 in July because the CP claimed he did not see the diagnosis of DM.

The DON stated that the CP should have reviewed Resident 1's previous medication orders from the last admission to the facility and the CP should have reviewed Resident 1's hospital records for the new admission this July.

The DON stated the CP should have reviewed Resident 1's H&P and the medications of Resident 1, which was also not reviewed by licensed nurses upon Resident 1's admission to the facility on 7/14/2025.

During a review of facility's P&P titled, Medication Regimen Review, dated June 2021, the P&P indicated the consultant pharmacist performs a comprehensive MRR at least monthly and the facility assured the consultant pharmacist had access to residents and the residents' medical records.