Health inspection·January 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure on resident safety by failing to provide supervision to one of two sampled residents (Resident 1) who were at high risk for falls. This deficient practice resulted to Resident 1 having an acute subdural hematoma (a blood clot that forms between the brain's surface and its tough outer covering) after he had a fall when he attempted to stand up from a sitting position at the facility's patio without staff supervision. Findings: During a review of the facility ' s investigation summary report, dated 1/7/2025, indicated that on the evening of 1/2/2025, a staff who was in the patio observed Resident 1 sitting on the patio ' s brick seating area. At around 9 PM, Resident 1 stood up using his front-wheeled walker and fell on his right side. The staff who immediately responded to the fall assessed Resident 1 and found a bump and a cut on the resident ' s right forehead. The facility called 911 (a universal emergency number) and sent Resident 1 to a general acute care hospital (GACH) for further evaluation per physician ' s order. During a review of Resident 1 ' s admission Record indicated that the facility admitted Resident 1 on 1/11/2011 and readmitted the resident on 1/5/2025 with diagnoses that included nontraumatic subdural hemorrhage (a rare condition that occurs without head trauma). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2024, indicated that Resident 1 ' s cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and touching or contact guard assistance as resident completes the activity) from a person when standing from a sitting position. During a review of Resident 1 ' s Change in Condition Evaluation report, dated 12/30/2024, indicated that he fell in the patio prior to the fall incident on 1/2/2025, but did not sustain any injury. During a review of Resident 1 ' s Fall Risk Evaluation, dated 12/30/2024, indicated that Resident 1 had a history of falls in the past three (3) months and had problem maintaining his balance while standing and has a decreased muscular coordination (a condition that causes a loss of muscle control and unsteady movements). During a review of Resident 1 ' s Physical Therapy Evaluation, dated 12/31/2024, indicated that (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 01/16/2025 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)