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Deficiency Records for Monrovia Post Acute
A list of the most recent deficiencies for Monrovia Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Monrovia Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-22 | 2024-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-22 | 2024-08-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-05 | 2024-04-29 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-04-05 | 2024-04-26 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-08 | 2024-03-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-08 | 2024-03-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-08 | 2024-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-03-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-08 | 2024-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-03-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-08 | 2024-03-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-08 | 2024-03-26 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-02-08 | 2024-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-03-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-08 | 2024-02-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-08 | 2024-02-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-08 | 2024-02-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | 2024-02-09 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-02-08 | 2024-02-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-04 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-05 | 2023-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-10 | 2023-06-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-10 | 2023-06-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-05-19 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-11 | 2023-05-15 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-11 | 2023-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-21 | 2023-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-02 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-22 | 2022-12-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-11-14 | Y |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2022-05-11 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-03-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-01 | 2021-08-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-01 | 2021-08-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-01 | 2021-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-01 | 2021-08-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-01 | 2021-08-04 | N |
| Post nurse staffing information every day. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-01 | 2021-08-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-01 | 2021-08-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-01 | 2021-08-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-08-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-09-23 | 2019-10-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-23 | 2019-10-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-23 | 2019-10-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-23 | 2019-10-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-23 | 2019-10-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-23 | 2019-10-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-23 | 2019-10-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-23 | 2019-10-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-23 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-23 | 2019-10-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
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