A list of the most recent deficiencies for Monrovia Post Acute. 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? |
---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-04 | 2023-08-25 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-05 | 2023-07-24 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-24 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-10 | 2023-06-02 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-10 | 2023-06-02 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-05-19 | Y |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-11 | 2023-05-15 | Y |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-11 | 2023-05-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-12-21 | 2023-01-24 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-02 | Y |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-22 | 2022-12-02 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-11-14 | Y |
Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2022-05-11 | 2022-07-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-03-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-07-08 | 2021-09-16 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-01 | 2021-08-04 | 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 | 2021-07-01 | 2021-08-04 | N |
Keep residents' personal and medical records private and confidential. | Health | 2021-07-01 | 2021-08-04 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-01 | 2021-08-04 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-01 | 2021-08-04 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-08-04 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-01 | 2021-08-04 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-08-04 | 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 | 2021-07-01 | 2021-08-04 | 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 | 2021-07-01 | 2021-08-04 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-01 | 2021-08-04 | N |
Post nurse staffing information every day. | Health | 2021-07-01 | 2021-08-04 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-01 | 2021-08-04 | 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 | 2021-07-01 | 2021-08-04 | N |
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-01 | 2021-08-04 | N |
Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-08-04 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-30 | 2021-08-04 | 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 | 2021-06-30 | 2021-08-04 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-30 | 2021-08-04 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-30 | 2021-08-04 | 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 | 2019-09-23 | 2019-10-23 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-23 | 2019-10-23 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-23 | 2019-10-23 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-23 | 2019-10-23 | N |
Provide activities to meet all resident's needs. | Health | 2019-09-23 | 2019-10-23 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-23 | 2019-10-23 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-23 | 2019-10-23 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2019-09-23 | 2019-10-23 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-23 | 2019-10-23 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-27 | 2019-10-23 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-27 | 2019-10-23 | N |
Conduct testing and exercise requirements. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Implement emergency and standby power systems. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Meet other general requirements that are deficient. | Fire Safety | 2018-10-01 | 2018-11-05 | 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 | 2018-10-01 | 2018-11-05 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Meet other general requirements. | Fire Safety | 2018-10-01 | 2018-11-05 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-09-24 | 2018-10-30 | N |
Ensure each resident receives an accurate assessment. | Health | 2018-09-24 | 2018-10-30 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-09-24 | 2018-10-30 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-24 | 2018-10-30 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-24 | 2018-10-30 | 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 | 2018-09-24 | 2018-10-30 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-24 | 2018-10-30 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-24 | 2018-10-30 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-24 | 2018-10-30 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-09-24 | 2018-10-30 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-24 | 2018-10-30 | 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 | 2018-09-24 | 2018-10-30 | 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 | 2018-09-24 | 2018-10-30 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-09-24 | 2018-10-30 | N |