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 (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: 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 02/18/2025 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)