Health inspection·July 3, 2024

F 0880 Provide and implement an infection prevention and control program. 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 implement the facility ' s infection surveillance tracking and heighten the facility ' s surveillance activities for coronavirus illness during periods of transmission to prevent and control the spread of Covid-19 (Coronavirus, a severe respiratory illness caused by a virus and spread from person to person) in accordance with current standards and the facility ' s policies and procedures. The facility failed to develop an effective line listing (a table/list that summarizes information about cases [possible, probable or confirmed] associated with an outbreak) for 20 out of a facility census of 98 who tested positive for Covid 19. Residents Affected - Some As a result, Resident 1 residing in Room A with a positive Covid 19 result was mistakenly moved to Room B to share a room with Residents 3 and 5 who were negative with Covid-19 during the facility ' s testing on 6/30/2024. These deficient practices had the potential to spread the Covid 19 to other residents, staff, visitors, and the community. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] to Room A, with diagnoses that included thoracogenic scoliosis (when a sideways curve affects your thoracic spine, or the upper and middle part of your back), sepsis (a serious condition in which the body responds improperly to an infection). A review of the facility Census for 6/29/2024 indicated Resident 1 was originally residing in Room A (and was Resident 2 ' s former roommate) A review of Resident 1 ' s History and Physical assessment dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of 6/07/2024, indicated Resident 1 cognition (thought process) was intact. The MDS indicated Resident 1 was dependent (helper does all of the effort) on task such showering, upper and lower body dressing. The MDS indicated Resident 1 required substantial /maximal assistance (helper does more than half) on task such as oral hygiene, toileting, and personal hygiene. A review of Covid-19 Rapid test results for Resident 1 dated 6/30/2024 indicated Type of test: Antigen, Rapid Test Results: Positive. (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 4 Event ID: 055989 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 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)