Health inspection·March 19, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Charting and Documentation, by failing to have complete documentation for one of three sampled residents (Resident 2). Resident 2 was found with purplish discoloration (any alteration in the skin's color, texture, or pigmentation) on the right great toe. This deficient practice resulted in not providing complete information about how Resident 2 sustained the purplish discoloration on the right great toe which had the potential to put Resident 2 ' s safety at risk. Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 2/2/2023, and readmitted Resident 2 on 12/11/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), and chronic systolic (congestive) heart failure (when the heart cannot pump blood well enough to give the body a normal supply). During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/4/2025, the MDS indicated Resident 2 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 2 was dependent (helper does all of the effort) on staff for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a review of Resident 2 ' s eINTERACT Change in Condition Evaluation (CIC), dated 2/3/2025, timed at 9:30 am, the CIC indicated Resident 2 had purplish discoloration to the right great toe. The CIC indicated there was no documentation about how Resident 2 got the discoloration on the right great toe. During a review of Resident 2 ' s Progress Notes (PN) for the month of February 2025, the PN indicated there was no documentation about how Resident 2 got the discoloration on the right great toe. During an interview on 3/18/2025 at 2:02 pm, with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 hit Resident 2 ' s right foot on something (unknown) during shower day. LVN 1 stated a Certified Nursing Assistant (CNA) (unknown), reported the incident to LVN 1 and LVN 1 did the skin assessment (a comprehensive evaluation of the skin, nails, and hair to identify any abnormalities or signs of disease, infection, or injury) of Resident 2 ' s right foot. (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 03/19/2025 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)