Health inspection·December 16, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide skin treatment in accordance with the professional standards of practice for one of three sampled residents (Resident 1) by failing to: Residents Affected - Few a. Ensure a Licensed Vocational Nurse (LVN) instead of a Certified Nursing Assistant (CNA) 1 applied ointments to Resident 1. b. Ensure there was a physician's order for the ointments being applied to Resident 1. These failures had the potential to result in improper use and application of skin treatment for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/27/2023 and recently admitted on [DATE] with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells) affecting left non-dominant side (the part of the body that is not used as much as the other side of the body), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and epilepsy (a brain condition that causes recurring seizures). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 1 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 was at risk of developing pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's Care Plan (CP), revised on 10/30/2024, the CP indicated Resident 1 was at risk for further skin breakdown related to history of skin breakdown and immobility (not being able to move around). The CP indicated to administer medications as ordered. The CP indicated to monitor and document for side effects and effectiveness. During a concurrent observation and interview on 12/16/2024 at 1:54 pm, with CNA 1, CNA 1 was observed providing care to Resident 1. CNA 1 was observed with gloves on and applied calmoseptine (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055141 Printed: 05/15/2026 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 055141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madera Post Acute Center 11900 Ramona Boulevard El Monte, CA 91732 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)