A list of the most recent deficiencies for El Monte Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-02 | 2024-02-23 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-02-02 | 2024-02-23 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-02-02 | 2024-02-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-02-02 | 2024-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-02 | 2024-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-02 | 2024-02-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-02 | 2024-02-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-02 | 2024-02-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-02 | 2024-02-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-02 | 2024-02-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-02 | 2024-02-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-02 | 2024-02-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-02 | 2024-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | 2024-02-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-02-02 | 2024-02-21 | N |
| Post nurse staffing information every day. | Health | 2024-02-02 | 2024-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-02 | 2024-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-02 | 2024-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-02 | 2024-02-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-02 | 2024-02-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-07 | 2024-02-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-07 | 2024-02-19 | N |
| Keep all essential equipment working safely. | Health | 2023-08-09 | 2023-08-29 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-07-06 | 2023-07-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-06 | 2023-07-27 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-06 | 2023-07-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-06 | 2023-07-27 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-10 | 2023-03-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-10 | 2023-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-10 | 2023-03-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-10 | 2023-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-10 | 2023-03-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-10 | 2023-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-10 | 2023-03-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-10 | 2023-03-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-10 | 2023-03-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-10 | 2023-03-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-10 | 2023-03-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-10 | 2023-03-22 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-10 | 2023-03-22 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-02-10 | 2023-03-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-02-10 | 2023-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-03-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-09 | 2023-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-09 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-09 | 2023-03-10 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-02-09 | 2023-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-09 | 2023-03-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-31 | 2019-11-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-11-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-31 | 2019-11-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-31 | 2019-11-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-31 | 2019-11-27 | N |
| Post nurse staffing information every day. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-11-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-11-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-31 | 2019-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-31 | 2019-11-27 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-10-31 | 2019-11-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-30 | 2019-11-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-30 | 2019-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-30 | 2019-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-30 | 2019-11-22 | N |
