Health inspection·August 27, 2025

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure swamp coolers (evaporative cooler, a device that cools air by using water evaporation) used in resident's rooms and in the facility were maintained in a safe and operable manner for two of three sampled residents (Resident 1 and Resident 2).This deficient practice had the potential to result in electrical resident care equipment not in safe operating conditions and affecting residents' wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/2/2019 and readmitted Resident 1 on 2/15/2025 with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and hypertension (high blood pressure).During a review of resident 1's History and Physical (H&P), dated 2/16/2025, the H&P indicated Resident 1 had capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/23/2025, the MDS indicated the resident had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with lower body dressing and showering/bathing self. The MDS indicated the resident was independent for eating, oral hygiene, upper body dressing and personal hygiene.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/21/2025 with diagnoses including sepsis (a life-threatening blood infection) and mycosis (fungal infections).During a concurrent observation and interview on 8/26/2025 at 2:21 PM with Resident 1, at the bedside of Resident 1, there was a swamp cooler in use. There was no water in the tank inside the swamp cooler. Resident 1 stated that the facility did not clean or change the filter and the water tank inside the cooler since it was placed inside the room at least a month ago.During a concurrent observation and interview on 8/26/2025 at 3:03 PM with Resident 2, at the bedside of Resident 2, there was a swamp cooler in use. Resident 2 stated that the facility did not clean or change the filter and the water container inside the cooler since Resident 2 was admitted .During an interview on 8/26/2025 at 3:47 PM with the administrator, the administrator stated that the maintenance and Infection Preventionist (IP) were responsible for maintaining and cleaning the swamp coolers. The administrator stated that there was no scheduled maintenance time for the coolers.During a concurrent interview and record review on 8/27/2025 at 12:18 PM with the administrator, the scheduled maintenance record was reviewed. The administrator stated there was no scheduled maintenance for the coolers. The administrator stated that the facility should maintain the coolers and the portable air conditioners following the facility's P&P and the manufacture manual for the electrical equipment.During an interview on 8/27/2025 at 3:38 PM with the interim Maintenance Director (MD), the MD stated there was no scheduled maintenance time for all the coolers.During a phone interview on 8/28/2025 at 11:05 AM with the IP, the IP stated there was no scheduled maintenance or cleaning time for all the coolers.During a review of the facility's P&P titled, Maintenance Service, revised Residents Affected - Some Page 1 of 2 055367 055367 08/27/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0908 Level of Harm - Minimal harm or potential for actual harm 12/2009, the P&P indicated, The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The P&P indicated, Maintenance personnel shall follow the manufacturer's recommended maintenance schedule.Records shall be maintained in the maintenance director's office. Residents Affected - Some 055367 Page 2 of 2