Glen Park at Monrovia

a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(5) Staffing plan, qualifications and duties.This evidence has not been met as required by: Based on record review and staff interview, the facility is not following the Plan of Operations regarding the fall policy and procedures, the staff called 9-1-1 without doing an assessment to check for severity of pain and injuries.

Based on observation, interview, the Administrator did not comply with the section cited above in that the exit points of the building, including the residents' rooms, had no signal systems which poses/posed a potential health, safety or personal rights risk to residentsns in care.

Based on observation, the Administrator did not comply with the section cited above in that the hot water temperature readings in random resident rooms (#5, #6, #9, #209, #212, #216) were below the required 105 - 120 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on observatio, the Administrator did not comply with the section cited above in that In some of the observed bathrooms, there were no grab bars and non-skid mats which poses/poned a potential health, safety or personal rights risk to residents in care.

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff...This requirement is not met as evidenced by: Based on interviews and review of documentation, R7's Medication Administration Record (MAR) for July 2024 is inaccurate. Staff initialed the medication log from July 2-8 2024 when R7 was hospitalized and has already left the facility which posed an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: During investigation it was found that the alleged incident did occur as R1 ate food that contained medication that was prescribed to R2 in error.

87469 87469 Advanced Directives and Requests Regarding Resuscitative Measures(c)If a resident who has an advance.......... experiences a medical emergency (3) Specifically for a terminally ill resident that is receiving hospice services ............ For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). The requirement is not met by evidenced by interviews and record review, the facility staff did not call 911 until June 5th, 2021 and resident was complaining pain since mid afternoon of June 3rd and even doctor advised to send R1 to hospital which posed an immediate risk to residents in care.