Monterey Healthcare & Wellness Centre, Lp

F-F726

Findings:

During a review of Resident 11 ' s Admission Record, the facility admitted Resident 11 on 6/20/2023 and readmitted Resident 11 on 1/17/2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), schizophrenia (a mental illness that was characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression [mental health condition that caused persistent feelings of sadness and loss of interest in activities] to elevated periods of emotional highs), and PTSD.

During a review of Resident 11 ' s Social Services Assessment document, dated 6/27/2023, the document indicated Resident 11 did have a history of recent trauma in the form of grief, separation, or death. This document indicated there was no documented evidence Resident 11 ' s triggers.

During a review of Resident 11 ' s Letter of Conservatorship (a legal document that appointed a conservator to make decisions on behalf of another person), dated 12/16/2024, the Letter of Conservatorship indicated, Resident 11 was gravely disabled due to a mental health disorder and reappointed Family member (FM) 1 and FM 2 as Resident 11 ' s conservator.

During a review of Resident 11 ' s care plans, initiated on 1/17/2025, the care plan indicated resident had a behavior problem related to schizophrenia, schizoaffective disorder, bipolar disorder, and PTSD. The care plan ' s interventions included anticipate the resident ' s needs, assist the resident in developing healthy coping skills, and monitor behavior episodes and attempt to determine underlying cause.

During a review of Resident 11 ' s History and Physical (H&P, a comprehensive physician ' s note regarding

the assessment of a resident ' s health status), dated 1/18/2025, the H&P indicated Resident 11 did not have

the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0740 During a review of Resident 11 ' s Baseline Care Plan document, dated 1/20/2025, the document indicated Resident 11 was admitted with diagnoses that included schizophrenia, schizoaffective disorder, bipolar Level of Harm - Minimal harm or disorder, PTSD, anxiety (increase feelings of fear, dread, and uneasiness), depression, auditory and visual potential for actual harm hallucination, suicidal ideation (SI, intrusive thoughts about death and dying oneself ), homicidal ideation (HI, intrusive thoughts of harming another person ), and substance abuse. Residents Affected - Few

During a review of Resident 11 ' s Minimum Data Set (MDS, a resident assessment), dated 1/24/2025, the MDS indicated Resident 11 was cognitively intact and had hallucinations. The MDS indicated Resident 11 had anxiety disorder, depression, bipolar disorder, schizophrenia, and PTSD. The MDS indicated Resident 11 was taking antipsychotics and antidepressants on a routine basis.

During a review of Resident 11 ' s care plan, initiated on 1/24/2025, the care plan indicated resident prefers to keep type of trauma private to avoid re-traumatization. The care plan ' s interventions included encourage resident ' s family ' s involvement, report psychological distress to the nurse, and to review resident ' s coping skills as much as possible.

During an observation on 2/11/2025 at 11:09AM in the facility ' s locked front patio, Resident 11 was wearing personal clothes standing still, arguing and talking to himself, and leaning forward.

During and observation on 2/12/2025 at 1:20PM in the facility ' s hallway connecting the enclosed locked front patio and the enclosed locked back patio, Resident 11 was seen yelling at the Assistant Director of Nursing (ADON). The ADON attempted to de-escalate and redirect Resident 11 back to his room. Resident 11 yelled, you probably just want to fuck me in the ass (impolite term that may refer to the buttocks) you faggot (a slur used to refer to gay men or other people of the queer community)!, while Resident 11 walked down the hallway back to his room with other staff members following him.

During a telephone interview on 2/14/2025 at 9:39AM with FM 1, FM 1 stated Resident 11 had a history of childhood trauma and PTSD. FM 1 stated, the facility never asked her about Resident 11 ' s history of PTSD and childhood trauma. FM 1 stated, Resident 11 had serious deep trauma and homophobia. FM 1 stated, the facility only treated Resident 11 for the voices in his head but never addressed the deep trauma Resident 11 experienced.

During an interview on 2/14/2025 at 3:00PM with Certified Nurse Assistant (CNA) 2, CNA 2 stated that she did not know about any residents with PTSD. CNA 5 stated, Resident 11 was normally quiet but if someone asked him to do something and he was in a bad mood, Resident 11 would respond in an agitated and loud voice and ask to be left alone. CNA 5 stated, Resident 11 would yell fuck and other curse words when he was angry towards the CNAs and Licensed Vocational Nurses (LVNs).

During a concurrent interview and record review on 2/14/2025 at 3:33PM with Registered Nurse (RN) 1, Resident 11 ' s Admission Record was reviewed. The Admission Record indicated Resident 11 was diagnosed with PTSD on 4/17/2024. RN 3 stated, Resident 11 had an official diagnosis of PTSD. RN 3 stated, Resident 11 would make homophobic comment such as you faggot, you like to take it in the ass, and you ' re a fucking homo (slur for a gay person), and curse words such as fuck and fuck you when he was angry towards male staff members.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0740 During an interview on 2/14/2024 at 3:45PM with the Administrator (ADM), the ADM stated, it was important to assess a resident with a diagnosis of PTSD for their triggers to prevent exposure to the resident and to Level of Harm - Minimal harm or prevent re-traumatization. potential for actual harm

During an interview on 2/14/2025 at 4:07PM with the ADON, the ADON stated, it was important to identify a Residents Affected - Few PTSD resident ' s triggers to prevent re-traumatization. The ADON stated, it was important to identify a PTSD resident ' s triggers because if the resident was re-triggered, the resident may be harmful to himself, other residents, and the staff members.

During a review of the facility ' s policy and procedure (P&P) titled Behavior/Psychoactive Medication Management, revised 1/25/2025, the P&P indicated if a resident exhibits mood or behavior problems upon admission, assessment will be conducted to address the resident ' s mood or behavioral status. The P&P indicated, the facility will identify the contributing factors related to the resident ' s mood/behavior and the non-medication interventions to be implemented. The P&P indicated, the Behavior Management/Psychoactive Review Committee will review the effectiveness of non-medication interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or 50012 potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of three residents Residents Affected - Few (Resident 28) does not receive Bactrim (Sulfamethoxazole-Trimethoprim an antibiotics or medication used to treat infection) unnecessarily by indicating in the physician's order how long the medication should be administered.

This deficient practice had the potential for Resident 28 to develop antibiotic resistance (medication not effective to treat infection) and results in adverse reaction (undesirable effect) health outcomes.

Findings:

During a review of Resident 28 ' s Admission Record (Face Sheet), the facility admitted Resident 28 on 5/30/2024 with diagnoses that included heart failure (failure of the heart to meet the body ' s demand), asthma (a chronic lung condition that causes inflammation and narrowing of the airways, making it difficult to breathe), schizophrenia (is a serious mental health condition that affects how people think, feel and behave) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 28 ' s History and Physical (H&P), dated 6/2/2024 indicated, Resident 28 does not have the mental capacity to make medical decisions.

During a review of Resident 28's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/3/2024, indicated the resident ' s cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and needed Setup or clean-up assistance from the staff for

the activities of daily living.

During a review of Resident 28's Order Summary Report (a physician ' s order), dated 2/14/2025, the Order Summary Report indicated an order on 5/31/2024 to give Resident 28 Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim a medication used to treat infection) give 1 tablet by mouth one time a day for HIV (Human Immunodeficiency Virus. It is a virus that attacks the body's immune system) without the stop date or how long the medication will be administered.

During a concurrent interview and record review on 2/14/25 at 12:21 PM, with the Infection Preventionist Nurse (IPN), IPN stated Resident 28 had been receiving Bactrim since admission to the facility due to a diagnosis of HIV. IPN stated, she was not aware that the resident was still receiving the antibiotic, as there was no documented end date for the prescription. IPN stated that Resident 28 remained on the antibiotic for

an extended period, significantly exceeding the recommended 14-day course for Bactrim. IPN stated prolonged use of antibiotic can cause resistance to the antibiotic. IPN stated she will contact the physician to discontinue the antibiotic, as it had been prescribed for nearly a year without reassessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0757 During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship , revised 2021, indicated The Facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of Level of Harm - Minimal harm or antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse potential for actual harm events associated with antibiotic use and improve outcomes for Residents.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50012

Residents Affected - Some Based on observation, interview and record review, the facility failed to follow the facility ' s proper sanitation and food handling practices by failing to ensure the Dietary Aide 1 (DA 1) adhere to properly securing hair with the hairnet without any hair exposed when assisting tray line ( process of preparing meals for the residents from the food preparation area to the meal trays) for 69 out of 69 residents residing in the facility.

This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food (transfer of bacteria, viruses, toxins [poisons] from the environment to the food ingested).

Findings:

During a dining observation on 2/13/25 12:19 PM, the DA 1 had hair exposed outside and visible outside of

the hairnet while assisting the cook with the preparation of the meal rays. In a concurrent interview DA 1 stated it was important to secure all hair within the hairnet to prevent contamination and the risks of infection or illness associated with exposed hair that could contaminate the food being prepared.

During an interview on 2/13/25 12:29 PM, [NAME] 1 stated that while DA 1 wore a hairnet, they had not the kitchen staffs had to ensured that all the hair was properly contained, allowing some no hair to be exposed.

The cook stated the risks associated with this deficiency, including the potential for contamination in food preparation areas and the facility ' s compliance with health and safety regulations.

During an interview on 2/14/25 2:29 PM with the Assistant Director of Nursing (ADON), the ADON stated whoever enters the kitchen should be wearing hair net and to ensure no hair was exposed.

During a review of the facility's policy and procedures titled, Dietary Department - Infection Control, revised in 2024, indicated Cover hair, beard, and mustache with an effective hair restraint, such as hats, hair coverings, or nets while in any kitchen and food storage areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50203 potential for actual harm Based on observation, interview, and record review, the facility failed to provide proper infection control Residents Affected - Some practices for 69 of 69 sampled resident by failing to ensure the facility's Water Management Program followed the approved national, state, and local measures to prevent and monitor the growth of Legionella (water-borne opportunistic bacteria)

These failures had the potential to contribute to poor infection control, improper cleaning and disinfection of

the resident's clothing and linens, growth of Legionella within the facility's water system which can lead to Legionnaires' disease (a serious pneumonia [lung infection] that can be fatal) which would affect all the residents and staff within the facility, and potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer.

Findings:

During an interview on 2/13/2025 at 10AM with the IP, the IP stated the facility does not test for Legionella unless there were 10 or more cases of pneumonia in the facility because testing for Legionella was very costly. The IP stated, there were five water heaters throughout the facility and the water heaters were flushed once a month, usually at the beginning of the month.

During a concurrent record review and interview on 2/13/2025 at 10:00AM with the IP, the facility ' s Water Heater Legionella Management Plan for November 2024, December 2024, and January 2025 were reviewed. The Water Heater Legionella Management Plan indicated the water heaters by the Breakroom, East Wing, [NAME] Wing, Laundry, and Kitchen were documented evidence under good and there was no documented evidence bad. The IP stated she did not know what good or bad meant. The IP stated the last time the facility ' s water heaters were checked was in January 2025. The IP stated it looked like the facility ' s water heaters had not been flushed for February 2025.

During a concurrent record review and interview on 2/13/2025 at 3:30PM with the IP, the facility ' s Water Management Plan, revised 2/6/2024, was reviewed. The IP indicated the facility ' s Water Management Plan did not have anything specific to legionella water management. The IP stated, she did not know if the Legionella Water Management Plan was based on a national standard. The IP stated, she did not know what Maintenance meant by flush the boilers. The IP stated, I go by what Maintenance and MS tell me.

During a record review of Direct Supply TELS. Work History Report, dated for January and February 2025,

the document indicated on 11/30/2024, 12/31/2024, and 1/31/2025, Maintenance marked the task description of water heater: flush to remove impurities, test pressure relief valve was marked done.

During a concurrent interview and record review on 2/13/2025 with the IP, the facility ' s policy and procedure (P&P) titled, Water Management, revised 5/25/2023, was reviewed. The P&P indicated the facility will survey

the facility using a risk assessment to determine its risk for Legionella growth and spread. The IP stated, she did not know about a risk assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0880 During a review of the facility ' s P&P titled Water Management, revised on 5/25/2023, the P&P indicated the facility will develop and utilize water management strategies, using the Core Elements of a Water Level of Harm - Minimal harm or Management Plan, to reduce the risk of growth and spread of Legionella and other opportunistic water-borne potential for actual harm pathogens in facility water systems. The P&P indicated the facility will follow national, state, and local guidelines to determine control measures based on the risk assessment and how to monitor them. Residents Affected - Some

During a review of the facility ' s P&P titled Water Management, revised on 5/25/2023, the P&P indicated physical and chemical measures recommended by the American Association of Heating Refrigeration and Air-Conditioning Engineers (ASRAE) that may be applied for the prevention and control of Legionella include, but are not limited to:

Quarterly measurement of water quality throughout the system to ensure charges that may lead to Legionella growth are not occurring.

Quarterly maintenance and monitor of disinfectant and other chemical levels in cooling towers and hot tubs.

During a review of the Centers of Disease Control and Prevention (CDC) document titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, the document indicated it was important to:

Identify building water systems for which Legionella control measures are needed

Assess how much risk the hazardous conditions in those water systems pose

Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella Growth and spread.

Make sure the program is running as designed and is effective.

During a review of the State Operational Manual (SOM), revised 8/8/2024, the SOM indicated the facility must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water system such as by having a documented water management program. The SOM indicated the water management plan must be based on national accepted standards, for example the American Society of Heating, Refrigerating, and Air Conditioning Engineers, the CDC, and the U.S Environmental Protection Agency. The SOM indicated, the control measures may include visible inspections, use of disinfectant, and temperature. The SOM indicated, monitoring such controls include testing protocols for control measures, acceptable range, and documenting the results of testing and should also include established ways to intervene when control limits are not met.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure four (4) out of twenty-two (22) resident's rooms (room [ROOM NUMBER], 5, 20, and 26) accommodated no more than four residents in each room. The 4 resident rooms consisted of 2 (two) - twelve (12) bed capacity rooms, 1 (one), seven (7) bed capacity room, and 1 (one), six (6) bed capacity rooms.

This deficient practice had the potential adversely affect the delivery of care, quality of life, safety and violate

the resident's rights for privacy.

Findings:

During the entrance conference interview, the Administrator (ADM) on 2/11/2025 at 9:20 AM, the ADM stated there were four rooms in the facility that occupied more than four residents in each room, but the facility had

a waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request an additional waiver this year. The ADM stated,

the multiple beds per room had no impact on care of the residents.

During a concurrent observation and interview on 2/11/2025 at 10:30 AM with Resident 51 in room [ROOM NUMBER], Resident 51 was observed walking around with his front wheel walker (a device that gives additional support to maintain balance or stability while walking) with no restriction. Resident 51 stated he had no concern with resident's space or the number of residents in his room.

During an interview on 2/12/2025 at 11 AM with Resident 65, Resident 65 stated he was sharing a room (room [ROOM NUMBER]) with other residents. Resident 65 stated, he had no concerns with the number of

the residents in his room.

During a review of the facility ' s Client Accommodations Analysis form, dated 2/12/2025, indicated the facility had 4 rooms (room [ROOM NUMBER], 5, 20, and 26) that had more than four residents per room.

During a review of the facility's request for additional room waiver dated 2/12/2025, indicated the arrangement of the rooms provided adequate space for nursing care, for wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability) access. The multiple beds per room and did not adversely affect the health and safety of the residents. The request indicated the following resident bedrooms were:

room [ROOM NUMBER] (12 beds) 12 residents, 79.1 sq. ft per resident.

room [ROOM NUMBER] (6 beds) 6 residents, 92.8 sq. ft per resident.

room [ROOM NUMBER] (12 beds) 12 residents, 87.1 sq. ft per resident.

room [ROOM NUMBER] (7 beds) 7 residents, 79.8 sq. ft per resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0911 During an interview on 2/13/2025 at 2:06 PM with Resident 119 in room [ROOM NUMBER], Resident 119 stated he was sharing room [ROOM NUMBER] with other residents. Resident 119 stated the room size was Level of Harm - Potential for okay and stated that the wheelchair and other equipment were used for other residents without any minimal harm restrictions. Resident 119 stated, he did not have any issue with the room size.

Residents Affected - Some During the survey, from 2/11/2025 to 2/14/2025, there were no observed adverse effects as to the adequacy of space, nursing care, comfort, and privacy to the residents. The residents residing in the affected rooms (Rooms 1, 5, 20, and 26) with an application for variance were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and lockers. There was adequate room for the operation and use of the wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents.

During a review of the facility's Resident Census from the last Health Recertification Survey with exit date of 3/15/2024 indicated the residents that occupied Rooms 1, 5, 20, and 26 were not the same residents that occupies Rooms 1, 5, 20, and 26 during this current Health Recertification Survey from 2/11/2025 to 2/14/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Some Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for twelve (12) out of twenty-two (22) resident rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31). The 12 resident rooms consisted of 1 (one), twelve (12) bed capacity room, 1 (one), seven (7) bed capacity room, 2 (two), four (4) bed capacity rooms, 2 (two), three (3) bed capacity rooms, and 6 (six), two (2) bed capacity rooms.

This deficient practice had the potential to negatively impact the quality-of-care and the ability to of the nursing care to safely provide care and privacy to the residents.

Findings:

During an entrance conference with the Administrator (ADM) on 2/11/2025 at 9:20 AM, the ADM stated multiple rooms in the facility did not have the required 80 square feet of space per resident, but the facility had a room waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request an additional waiver this year. The ADM stated, the room size had no impact on the care of the residents.

During a concurrent observation and interview on 2/11/2025 at 10:30 AM with Resident 51 in room [ROOM NUMBER], Resident 51 was observed walking around with his front wheel walker (a device that gives additional support to maintain balance or stability while walking) with no restriction. Resident 51 stated he had no concern with resident's space in his room.

During a concurrent observation and interview on 2/11/2025 at 10:51 AM with Resident 29 in room [ROOM NUMBER], Resident 29 was observed moving around the room in her wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability) with no restriction. Resident 29 stated, she had no issue with the space in the room.

During an interview on 2/12/2025 at 9:55 AM with Resident 56, Resident 56 stated, he was sharing room [ROOM NUMBER] with other residents and had no concerns with his room size.

During a review of the facility ' s Client Accommodations Analysis form, dated 2/12/2025, indicated the facility had 12 rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31) that measured less than the required 80 square footages per resident in multiple bed capacity rooms.

During a review of the facility's request for room waiver, dated 2/12/2025, indicated the arrangement of the rooms provided adequate space for nursing care, for wheelchair access, and did not adversely affect the health and safety of the residents. The request indicated the following resident bedrooms were:

room [ROOM NUMBER] (12 beds) 12 residents 56x20 sq. ft., 79.1 sq. ft per resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0912 room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident.

Level of Harm - Potential for room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident. minimal harm room [ROOM NUMBER] (2 beds) 2 residents 11x12 sq. ft., 63 sq. ft per resident. Residents Affected - Some room [ROOM NUMBER] (2 beds) 2 residents 12x13 sq. ft., 75 sq. ft per resident.

room [ROOM NUMBER] (2 beds) 2 residents 12x12 sq. ft., 70 sq. ft per resident.

room [ROOM NUMBER] (4 beds) 4 residents 12x23 sq. ft., 67 sq. ft per resident.

room [ROOM NUMBER] (7 beds) 7 residents 25x23 sq. ft., 79.8 sq. ft per resident.

room [ROOM NUMBER] (2 beds) 2 residents 12x14 sq. ft., 66.5 sq. ft per resident.

room [ROOM NUMBER] (4 beds) 4 residents 12x25 sq. ft., 72 sq. ft per resident.

room [ROOM NUMBER] (3 beds) 3 residents 12x20 sq. ft., 78 sq. ft per resident.

room [ROOM NUMBER] (3 beds) 3 residents 12x20 sq. ft., 78 sq. ft per resident.

During an interview on 2/13/2025 at 2:06 PM with Resident 119 in room [ROOM NUMBER], Resident 119 stated he was sharing room [ROOM NUMBER] with other residents. Resident 119 stated the room size was okay and stated that the wheelchair and other equipment were used for other residents without any restrictions. Resident 119 stated, he did not have any issues with the room size.

During the survey, from 2/11/2025 to 2/14/2025, there was no observed adverse effects related to the inadequate room size during nursing care. The residents residing in the affected rooms (room [ROOM NUMBER], 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31) with an application for variance were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and lockers. There was adequate room for the operation and use of the wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents.

During a review of the facility's Resident Census from the last Health Recertification Survey with exit date of 3/15/2024 indicated the residents that occupied Rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30 and 31 were not

the same residents that occupies Rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30 and 31 during this current Health Recertification Survey from 2/11/2025 to 2/14/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 555897 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555897 B. Wing 02/14/2025

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)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 50203

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 69 or 69 residents, staff and the public by failing to:

1. Ensure the facility's washing machine Lint Cleaning Log for 2/12/2025 and 2/13/2025 were completely filled out to indicate the facility's lint screens (lint trap, a device that catches lint and debris from laundry) were cleaned from the clothes dryer.

These failures had the potential to cause a facility fire by not tracking when lint screens were cleaned out from the clothes dryer.

Findings:

During a concurrent interview and record review on 2/13/2025 at 8:50AM with Laundry Services (LS), the facility's Lint Cleaning Log for 2/10/2025 to 2/12/2025 was reviewed. The Lint Cleaning Log indicated on 2/12/2025 at 4:00PM there was no documented evidence the lint screens were cleaned for two of three dryer machines. The LS stated, on 2/13/2025 at 8:30AM, there was no documented evidence the lint screens were cleaned for three of three dryer machines. The LS stated the lint screens were cleaned every 2 hours on at 8AM, 10AM, 12PM, 2PM, 4PM, and 6PM schedule. The LS stated it was important to clean the lint screens because of the possibility of a fire.

During a concurrent interview and record review at 2/13/2025 at 8:50AM with the Infection Preventionist (IP),

the facility's Lint Cleaning Log for 2/10/2025 to 2/12/2025 was reviewed. The IP stated, according to the lint cleaning log, the last dryer lint screen check was done on 2/12/2025 at 4PM for one dryer machine. The IP stated, she cannot be sure the last schedule person on 2/12/2025 cleaned the lint screens because it was not documented. The IP stated, if the lint screens were not cleaned regularly, there was a potential for a fire throughout the facility.

During a review of the facility's policies and procedures (P&P) titled Laundry - Safety, revised 1/1/2012, the P&P indicated all machines and appliances are checked daily to make sure they are clean, operating correctly free of defects .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 555897