Health inspection·February 18, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances verbalized by one of two sampled residents' (Resident 1) responsible party (RP) apprised of progress towards resolution. In addition, the facility failed to issue a written grievance decision to the resident and RP, in accordance with the facility's policy on Grievance/Concern. This deficient practice increased the risk for negative psychosocial impact on Resident 1's quality of life. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic encephalopathy (a condition in which the brain does not function properly due to an underlying metabolic imbalance),acute respiratory failure with hypoxia(a condition when the body doesn't get enough oxygen). During a review of Resident 1's History and Physical [H&P] dated 02/07/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Sets (MDS - a federally mandated resident assessment tool), dated 2/09/2025, indicated Resident 1's cognition (ability to think, remember, and reason with no difficulty) was severely impaired. During an interview and record review of the facility's grievance log on 2/18/2025 at 12:00 PM with the Social Service Director (SSD), the SSD stated she is the person assigned to respond to grievances filed by residents or family members. The SSD stated she starts by talking to the person who files the grievance to clarify information and fills out the grievance form. The SSD then stated she would immediately forward the grievance information to the specific department where the concern is being raised. The SSD then stated the grievance process is completed as soon as possible and takes approximately 2 days for SSD to finalize and inform the reporting party of the outcome. The SSD stated she had not received any concerns or grievances from residents or family members since October of last year (2024). During a telephone interview on 2/18/2025 at 1:15 pm with Resident 1's RP, RP stated she was in the facility visiting Resident 1 either Sunday (2/16/2025) or Monday (2/17/2025) when Social Service Assistant (SSA) came into the room to ask if everything in the facility was okay. RP stated she Page 1 of 2 055989 055989 02/18/2025 Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few informed the SSA that when Resident 1 was admitted to the facility on [DATE], the admitting nurse was very aggressive when changing Resident 1 and rude with Resident 1 and the RP. The RP stated the SSA just said ok and wrote down on a piece of paper and left the room. The RP stated the SSA did not asked her if she wanted to file a grievance or informed if someone would look into her verbalized concern. The RP stated no one had called her from the facility or followed up from the facility in regard to her verbalized concern to SSA. During an interview on 2/18/2025 at 2:45 PM with SSA, the SSA stated she was instructed this past weekend to go around the facility and ask about customer experience questions. The SSA stated she spoke to Resident 1's RP on 2/17/2025, when RP informed her, she had experienced rudeness from some of the facility nurses. The SSA stated she did not ask RP to elaborate what she meant by rudeness and just wrote down the concern. The SSA stated she had not started a grievance for RP but informed the DON that morning (2/17/2025) and was in the process of submitting a customer satisfaction survey but had not finalized the survey. The SSA stated SSD was in charge of facility grievances, but she had not informed SSD yet of the RP concerns. During an interview on 2/18/2025 at 2:58 with SSD, the SSD stated the customer satisfaction survey was something she had developed a week ago along with the administrator. The SSD stated she instructed the SSA to walk around the facility and complete the customer satisfaction survey. The SSD stated if there were any family or resident concerns verbalized during the customer satisfaction survey, she would expect to be informed so she could start a grievance process and investigate. The SSD stated she was not aware that RP had verbalized concerns, otherwise, she would have started a formal written grievance and called the RP, then forward the grievance to the appropriate department. During an interview on 2/18/2025 at 3:00 PM with the Director of Nursing (DON), the DON stated she was not aware of any resident or family complaints regarding any nurses' treatments. The DON stated if she was aware she would start an investigation. During a review of the facility's policy and procedure titled Resident and Family with a revision date of 2/22/2023, the policy indicated It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy further indicated Prompt efforts to resolve, included the facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. 055989 Page 2 of 2