Health inspection·August 6, 2024

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 Page 1 of 2 555897 555897 08/06/2024 Monterey Healthcare & Wellness Centre, LP 1267 San Gabriel Blvd Rosemead, CA 91770

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. 555897 Page 2 of 2