Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monterey Park Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Failure to Perform Hand Hygiene During Food Preparation: A dietary staff member handled ready-to-eat pies with an ungloved hand, touched a trash can lid and then bread without washing hands, and later pulled up pants while wearing gloves before returning to prepare hamburger buns without washing hands or changing gloves. The facility's handwashing policy required hand hygiene before and after handling food and after personal grooming activities, and the Dietary Director acknowledged awareness of staff not always washing hands and the risk of cross contamination.
A resident with a history of falls and cognitive deficits experienced a fall in the shower room and was assisted by staff, but the emergency contact and physician were not notified until several hours later. Documentation did not reflect immediate notification, and staff interviews confirmed the delay, resulting in the family learning of the incident only during a subsequent medical appointment, after which a knee fracture was diagnosed.
A mechanical lift in a resident room had a buildup of grime and particles on the base during repeated observations. The lift was used by a resident dependent on a mechanical lift. Staff gave differing accounts of cleaning expectations, including every shift, nightly, weekly, after each use, or by housekeeping after maintenance checks.
A resident who was moderately cognitively impaired and needed staff help with ADLs had a care plan calling for the call light to be clipped within easy reach, along with a Call Don't Fall sign and reminders to ask for assistance. However, repeated observations showed the call light draped over a pillow on a chair, on the floor under a chair, or across a bedside table several feet away from the resident. CNA, LPN, ADON, and Corporate Nurse interviews confirmed call lights should be within arm’s reach and checked before staff left the room.
Improper Foley catheter tubing placement was observed for a resident with obstructive and reflux uropathy who required total assistance and had orders for Foley care each shift. The catheter bag was placed under the wheelchair, but the tubing was seen dragging on the ground with thick cloudy substance in it, and a CNA emptied the bag without repositioning the tubing. Staff stated the tubing should not touch or drag on the ground and that nursing and CNA staff were responsible for its placement.
A dietary manager responded aggressively to a resident's meal preference concerns during a council meeting, slamming hands on the table and yelling, which caused the resident to cry and feel belittled. Multiple staff witnessed the incident and reported the manager's disrespectful behavior, with prior complaints noted. The resident, who had cognitive and communication needs, was visibly upset by the interaction.
A CMT administered the wrong medications to a severely cognitively impaired resident after failing to properly verify the resident's identity and medication details against the eMAR. The error was discovered when the CMT realized the mix-up while preparing medications for another resident. The resident received several medications not ordered for them, but did not experience any adverse reactions. The incident was reported and the resident was monitored.
Two residents in the facility did not receive appropriate transfer techniques, as staff failed to use gait belts during transfers. One resident, who required moderate assistance, expressed concerns about staff not using the gait belt, leading to discomfort and fear of falling. Another resident, requiring supervision, refused the gait belt due to discomfort, and staff used clothing to assist with transfers instead. Interviews revealed that staff were expected to use gait belts, but this was not consistently practiced.
Failure to Perform Hand Hygiene During Food Preparation
Penalty
Summary
The kitchen staff member failed to wash hands during food preparation activities. During observation on 9/25/25 from 9:30 A.M. to 12:00 P.M., Dietary [NAME] A grabbed ready-to-eat pies with an ungloved hand, with the full length of the thumbs touching the top of the pies while moving them. The same staff member touched the gray garbage can lid on the large trash can without gloves, then picked up a loaf of bread, went to the three-compartment sink, and then to the dishwasher without washing hands. Later in the same observation, while working on the preparation line handling hamburger buns, Dietary [NAME] A was wearing gloves but pulled up his/her pants and then returned to preparing hamburger buns without washing hands and changing gloves. The facility's undated handwashing policy stated that hand washing was required before and after handling food, after toileting or personal grooming, and after other specified activities. During interview on 9/26/25 at 9:00 A.M., the Dietary Director said he/she was aware of staff not always washing their hands and the risk of cross contamination and stated that since starting three weeks earlier, he/she had already created a schedule of education topics including handwashing.
Failure to Timely Notify Emergency Contact After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's emergency contact in a timely manner following an incident where the resident's knees buckled, resulting in staff lowering the resident to the ground in the shower room. The resident, who had a history of falls, cerebral infarction, and cognitive communication deficit, was found on the floor but denied pain or injury at the time. Documentation showed that the nurse and staff assisted the resident back into a wheelchair and noted that all appropriate parties were notified, but did not specify who was contacted or when. Further review of the incident report revealed that the resident's family member, listed as the emergency contact, was not notified until several hours after the incident. The physician was also notified later in the day. There was no documentation in the progress notes indicating immediate notification of the family member or emergency contact after the fall. The delay in notification became apparent when the family member, during a doctor appointment with the resident, learned of the incident and subsequently took the resident to the emergency room, where a right knee fracture was diagnosed. Interviews with facility staff confirmed that the assigned nurse did not notify the family member immediately after the incident, and that documentation of such notifications was lacking. The facility's policy on notification of change was requested but not provided at the time of the survey exit. Staff interviews indicated an expectation that the charge nurse or unit ADON would be responsible for timely notification and documentation, but this did not occur in this case.
Mechanical Lift in Resident Room Had Buildup of Grime
Penalty
Summary
The facility failed to maintain a mechanical lift in resident room [ROOM NUMBER] free from a buildup of grime and particles. Observations on 9/23/25 at 11:52 A.M. and 9/25/25 at 12:58 P.M. showed grime on the base of the lift used by one resident who was dependent on a mechanical lift. The facility’s undated guidelines for inspecting mobile lifts stated that all surfaces should be inspected to ensure they are in good repair and cleaned as necessary, with housekeeping notified. During interviews, CNA A said the lift should be cleaned every shift and more often by staff who use it, CNA B said it should be cleaned at night and disinfected after every use, the North Unit ADON said it should be cleaned weekly, another North Unit ADON said housekeeping was supposed to clean the lifts after maintenance checked them, and the North Unit Side ADON said housekeeping should clean the lift and aides should notify housekeeping when cleaning is needed.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one sampled resident, Resident #18, who was moderately cognitively impaired and required staff assistance with activities of daily living. The resident’s care plan identified limited physical mobility, unsteady gait, poor safety awareness, and interventions that included displaying a Call Don't Fall sign, educating the resident to ask staff for assistance, educating the resident to use the call light, and ensuring the call light was clipped where the resident could easily reach it. Multiple observations showed the resident’s call light was not within reach. It was seen draped across a pillow on a chair at least 2 feet away from the resident on several occasions, on the floor under a chair, and draped across a bedside table positioned about 3 feet away. A Call Don't Fall sign was posted in the room during these observations. During interviews, CNA E, LPN A, the ADON, and the Corporate Nurse stated that call lights should be within arm’s reach at all times, that staff were responsible for ensuring this before leaving the room, and that if a call light was out of reach it should be clipped to the resident’s person.
Improper Foley Catheter Tubing Placement
Penalty
Summary
Failure to provide appropriate catheter care was identified for one resident with an indwelling Foley catheter. The resident was admitted with obstructive and reflux uropathy, was cognitively intact, required total assistance for all cares and transfers, and had a care plan directing staff to keep the catheter bag and tubing below the level of the bladder. The physician orders included Foley catheter care each shift and changing the drainage bag as needed for leaking. The facility policy stated to keep the catheter and tubing free of kinks and to check the drainage tubing and bag to ensure proper drainage. During observation, the resident was seen sitting in a wheelchair with the catheter drainage bag hooked underneath the wheelchair in a privacy bag, while the tubing had a creamy thick substance in it and was clipped to the resident’s pant leg. On a later observation, the catheter tubing was dragging on the ground under the wheelchair and had thick cloudy substances in the tubing. During another observation, the tubing remained on the ground while a CNA emptied the drainage bag and did not reposition the tubing so it was not touching or dragging on the ground. Staff interviews confirmed that catheter tubing should not touch or drag on the ground, should be repositioned if found on the ground, and that nursing and CNA staff were responsible for ensuring proper placement.
Failure to Treat Resident with Dignity During Resident Council Meeting
Penalty
Summary
A deficiency occurred when a dietary manager failed to treat a resident with dignity and respect during a resident council meeting. The resident, who had diagnoses including dysphagia, cognitive communication deficit, and major depressive disorder, was cognitively intact and valued making personal decisions. During the meeting, the resident expressed concerns about not liking fish and requested an alternative meal. In response, the dietary manager became belligerent, slammed their hands on the table, and yelled, "What do you want me to do about it?" This aggressive behavior caused the resident to become visibly upset and cry in front of others. Multiple staff members, including the Director of Rehab, Business Office Manager, and Social Services Director, witnessed the incident and described the dietary manager's actions as harsh, aggressive, and disrespectful. The Business Office Manager felt so uncomfortable with the dietary manager's response that they left the meeting to involve the administrator. The Social Services Director documented a grievance on behalf of the resident, noting that the resident was visibly upset and negatively affected by the dietary manager's behavior. Other complaints about the dietary manager's treatment of residents had also been received in the past. The administrator and Director of Nursing confirmed awareness of the incident and stated that the dietary manager was removed from the meeting and subsequently terminated. The resident reported feeling belittled and embarrassed during the incident but later felt safe and supported by other staff and residents. The facility did not provide a policy for dignity and respect when requested during the investigation.
Significant Medication Error Due to Failure in Resident Identification and Medication Verification
Penalty
Summary
A significant medication error occurred when a certified medication technician (CMT) administered the wrong medications to a resident with chronic systolic heart failure, high blood pressure, dementia, and ulcerative colitis. The resident was severely cognitively impaired and unable to communicate what had happened. The CMT, after giving medications to the resident's roommate, prepared medications for another resident and mistakenly gave that resident's medications to the cognitively impaired resident instead. The error was discovered when the CMT attempted to give medications to the intended recipient and realized the mistake. The medications administered in error included Atorvastatin, Baclofen, Apiraban (Eliquis), and Mirtazapine, none of which were ordered for the resident who received them. The facility's policies and medication pass tips require staff to verify resident identity and medication details against the electronic Medication Administration Record (eMAR), but these procedures were not followed in this instance. Upon notification of the error, the resident was assessed by an LPN, and vital signs were taken. The nurse practitioner, assistant director of nursing, family, and hospice were notified. The resident was monitored for adverse reactions, but none were observed. The incident was documented, and the physician confirmed that the resident should be monitored for any adverse effects due to the single dose of incorrect medications.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to ensure appropriate transfer techniques were utilized for two residents, leading to deficiencies in care. Resident #1, who was cognitively intact and used a wheelchair for mobility, required partial, moderate assistance for transfers. Despite the resident's care plan indicating the need for a gait belt during transfers, the resident expressed concerns about staff not using the gait belt, which led to discomfort and fear of falling. The resident specifically mentioned that CNA A and most staff did not use the gait belt, and this issue was discussed during the resident's care plan meeting. Resident #3, also cognitively intact and using a wheelchair, required supervision and assistance with transfers. During an observation, CNA A attempted to use a gait belt but stopped when the resident expressed discomfort. Instead, CNA A used the resident's clothing to assist with the transfer, which is not in line with the facility's transfer protocol. CNA A admitted to not using a gait belt with Resident #3 and only sometimes with Resident #1, relying on the residents' ability to stand on their own. Interviews with facility staff, including the ADON and DON, revealed that CNAs are expected to use gait belts for all transfers unless a mechanical lift is required. The DON was unaware of any resident refusing the gait belt and expected staff to inform them of such refusals for care planning. The facility had conducted in-service training on gait belt use, but CNA A admitted to not consistently using the gait belt until the resident began wearing it all the time.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Blue Springs | 0.4 mi | ★★★★★ | 0 | 0 |
| Jackson Creek Post Acute | 0.8 mi | ★★★★★ | 21 | 0 |
| Sunterra Springs Independence | 1.3 mi | ★★★★★ | 0 | 0 |
| Abode Health And Wellness Center | 3.3 mi | ★★★★★ | 6 | 0 |
| Wilshire At Lakewood Rehab Center | 3.7 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.