F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop a care plan for one of two sampled Residents
(Resident 1) that included specific interventions to monitor resident's behaviors who goes out on pass and
with had a history of drug abuse.
This deficient practice had the potential for residents to not receive appropriate care, treatment, and/or
services.
Findings:
A review of Resident 1's admission Record indicated a readmission to the facility on 5/16/2024 with
diagnoses that included encephalopathy (group of conditions that cause brain dysfunction), schizoaffective
disorder (mental health condition that is marked by a mix of schizophrenia [mental health condition that
affects how people think, feel, and behave] symptoms such as hallucinations [false perception of objects or
event involving the senses], delusions [belief or altered reality], and mood disorder symptoms such a
depression [mental health disorder characterized by persistently depressed mood or loss of interest in
activities], mania [extremely elevated and excitable mood]), and psychoactive substance (mind-altering
drug or consciousness-altering drug that change brain function and results in alterations in perception,
mood, consciousness, cognition, or behavior) abuse.
A review of Resident 1's History and Physical assessment dated [DATE] indicated Resident 1 was able to
make decisions for activities of daily living.
A review of Resident 1's latest comprehensive Minimum Data Set (MDS, a standardized assessment and
care planning tool), dated 7/29/2024, indicated the resident was cognitively (ability to think and reason)
intact.
A review of Resident 1's Physician Order Summary indicated for the following:
a) On 8/1/2024, the physician prescribed Resident 1 may go out on pass with mother on 8/3/2024 for lunch,
one time only.
b) On 8/3/2024, the physician prescribed Resident 1 may go out on pass with brother on 8/3/2024.
A review of Resident 1's General Acute Care Hospital (GACH) Consultation Report dated 5/10/2024, timed
at 8:33 AM indicated, Resident 1 had a past medical history of schizophrenia, hypertension (high blood
pressure), hyperthyroidism (when the thyroid gland makes too much thyroid hormone, speeds up
(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:
555897
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
555897
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monterey Healthcare & Wellness Centre, LP
1267 San Gabriel Blvd
Rosemead, CA 91770
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the body's metabolism), depression and drug abuse. The consultation report indicated Resident 1 had a
social history of smoking, alcohol and methamphetamine (stimulant [class of drug that increase the activity
of the brain] that affects the behavior, mental and central nervous system) use.
During a concurrent interview and record review of Resident 1's care plans on 8/6/2024 at 4:04 PM, the
Director of Nursing (DON) stated there was no documented evidence of a care plan initiated for Resident
1's history of drug use and out on pass. The DON stated she was aware Resident 1 had a history of drug
use, but was not in Resident's plan of care because he was not actively using any drugs at facility. The
DON stated Resident 1 going out on pass was never a part of resident's plan of care because the facility
has not initiated care plans for out on pass.
During an interview with the DON on 8/6/2024 at 5:13 PM, the DON stated there was communication within
the staff to know what interventions need to be done when residents return from out on pass. The DON
stated there was no policy, care plan and that interventions/instructions to staff regarding residents plan of
care was done verbally, there is nothing on writing. The DON stated the importance of care planning is to
make sure there a specific interventions for resident and what to monitor when residents go out on pass.
A review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning,
dated 11/2018 indicated the facility was to provide person-centered, comprehensive and interdisciplinary
care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and
environmental needs of residents in order to obtain or maintain the highest physical, mental, and
psychosocial well-being.
A review of the facility's policy and procedure (P&P) titled Out on Pass dated 1/11/2016 indicated the facility
was to provide person-centered, comprehensive and interdisciplinary care that reflects best practice
standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in
order to obtain or maintain the highest physical, mental, and psychosocial well-being.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555897
If continuation sheet
Page 2 of 2
