Health inspection·March 13, 2025

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the licensed staff verified Resident 1 ' s admission orders from the facility, by reviewing Resident 1 ' s medical history and general acute care hospital (GACH 1) discharge orders upon readmission to the facility on 3/12/2025, for one of two sampled residents (Resident 1), when it failed to: Residents Affected - Few As a result of this deficient practice, Resident 1 had the potential to not receive the care and services, and correct medications needed for the resident ' s diagnosis while in the facility. Findings: During a review of facility ' s admission Record indicated Resident 1 was initially admitted on [DATE] but readmitted back to the facility from GACH 1 on 3/12/2025, with diagnoses that included Schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 1 ' s History and Physical (H&P), dated 2/23/2025, indicated the resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s GACH 1 Patient ' s Home Medication on Discharge dated 3/12/2025 indicated continue taking the following medications 1.Quetapine (a medication used for Schizophrenia) 150 milligrams oral tablet 1 tab orally 2 times a day During a review of Resident 1 ' s GACH 1 Telemetry-Clinical Summary Report dated 3/11/2025 indicated the following medication: 1. Quetiapine give 100 milligrams tablet oral at bedtime, the report indicated the status as active. During a review of a facility document titled Order Summary report dated March 13,2025, indicated an order for the following medication: 1. Seroquel (Quetiapine) oral tablet 100 milligrams, give 1 tablet by mouth at bedtime for Schizophrenia manifested by paranoid delusion thinking everyone is against him. Page 1 of 2 555897 555897 03/13/2025 Monterey Healthcare & Wellness Centre, LP 1267 San Gabriel Blvd Rosemead, CA 91770

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of an SMS (short Message Service, refers to standard text messages sent using a cellular signal) sent by Registered Nurse 1 to Physician 1 on 3/12/2025 timed at 10:20 pm, the SMS message indicated 7 images containing Resident 1 ' s face sheet and Facility ' s Order Summary Report with an active order date of 3/13/2025 and a message addressed to Physician 1 stating This is RN 1 from (Facility), Resident 1 is readmitted to the facility, attached is the resident ' s medication list the message showed a read notification of yesterday (3/12/2025) under the message. During a telephone interview with RN 1 on 3/13/2025 at 2:35 PM, RN 1 stated she was the nurse who completed Resident 1 ' s admission orders to the facility on 3/12/2025. RN 1 stated she reviewed Resident 1 ' s GACH Telemetry-Clinical Summary Report based on the medication on the report that indicated active, RN 1 stated she input the medications into Resident 1 ' s facility admission orders. RN 1 stated she did not verbally speak to Physician 1. RN 1 stated that once she completed Resident 1 ' s admission orders she sent Physician 1 an SMS- text message from her personal phone to inform him of Resident 1 ' s admission and medication orders. RN 1 stated this was the common practice at the facility to inform Physician 1. RN 1 stated if Physician 1 did not respond to the message, but the message indicated it was read, it was understood Physician 1 agreed to the medication orders texted to him. RN 1 stated she did not see Resident 1 ' s GACH Patient ' s Home Medication on Discharge documents and only went based on Resident 1 ' s GACH Telemetry-Clinical Summary Report and Resident 1 ' s previous medication while at the facility to input Resident 1 ' s readmission orders. During an interview with on 3/13/2025 at 3:18 AM with the Director of Nursing (DON), the DON stated that during admission and readmission, licensed nurses should be going over the discharge summary list from the originating GACH to the physician. The DON stated sometimes physicians would ask the facility some questions regarding the residents ' GACH stay and the facility ' s admitting nurse will then go over all hospital medications and physicians would tell the licensed nurses what to continue and discontinue. The DON stated all admitting nurses should be calling and verbally talking to the admitting physicians, to ensure the admitting physician agrees with the resident ' s admission orders. A review of facility ' s policy titled admission and Orientation of Residents with a revision date of October 2017, indicated 3. Upon admission, the residents attending Physician will provide the following information to the admissions office: an order for skilled nursing care, the type of diet the resident requires, Medication orders, including medical condition or problems associated with each medication 555897 Page 2 of 2