Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 an
observation, interview, and record review, the facility staff failed to ensure one of four sampled residents
(Resident 4) was free of accident hazards by leaving an unattended bottle of cleaning solution in the
shower and failing to supervise Resident 4 who had a history of wandering (when a resident roams around
and becomes lost or confused about his/her location).
This deficient practice resulted in Resident 4 to gain access to the bottle of cleaning solution on 5/2/24 and
was observed holding the bottle tilted towards the resident's mouth. This failure also had the potential for
other residents to have access to the bottle of cleaning solution and risk for ingesting the cleaning solution,
which could lead to harm and hospitalization.
Findings:
A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on
[DATE] and was readmitted on [DATE] with diagnoses that included hypercalcemia (a condition in which the
calcium level in the blood becomes too high), dementia (a brain disorder that results in memory loss, poor
judgment, and confusion), and dysphagia (difficulty or discomfort in swallowing).
A review of Resident 4's History and Physical Examination (H&P), dated 3/14/2024 indicated Resident 4
did not have the capacity to understand and make decisions.
A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool),
dated 2/7/2024, indicated Resident 4 was assessed having severely impaired cognitive (mental action or
process of acquiring knowledge and understanding) skills for daily decision making and required partial
moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, sit to
lying, sit to stand, wheel 50 feet (ft- unit of measurement) with two turns (the ability to wheel at least 50 feet
and make two turns once seated in wheelchair/scooter), and wheel 150 feet (the ability to wheel at least
150 feet in a corridor or similar space once seated in wheelchair/scooter).
A review of Resident 4's Care Plan, revised on 2/6/2024, indicated Resident 4 was observed at risk for
physical behaviors: wandering. The care plan indicated Resident 4's risk factors included impaired cognition
secondary to dementia and impaired safety awareness/safety judgement. Resident 4's care plan
interventions indicated to redirect resident to resident care areas when indicated.
A review of Resident 4's Change in Condition Evaluation form, dated 5/2/2024, indicated Resident 4 was
witnessed by Certified Nursing Assistant (CNA) holding a bottle of cleaning solution in Station
(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 3
Event ID:
055153
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
055153
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Montebello Care Center
1035 W Beverly Blvd
Montebello, CA 90640
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2 shower room. The COC also indicated; Resident 4 was also witnessed spitting something out. The COC
further indicated, Registered Nurse (RN) did the assessment and called Poison Control Center. The COC
indicated RN was directed by the Poison Control Center to provide resident with water or milk and Resident
4 refused water did drink the milk.
During an interview with Housekeeping Supervisor (HKS), on 5/15/2024, at 11:19 AM, HKS stated cleaning
solutions are stored and locked in the housekeeping carts after use. HKS stated housekeeping staff are not
allowed to leave any cleaning solutions or chemicals in the bathrooms or showers and/ or other areas that
can be accessed by the residents. HKS stated on 5/2/2024 Housekeeper (HK 1) left a bottle of cleaning
solution in Shower 2. HKS stated in the evening of 5/2/2024, Resident 4 was found by CNA 1 and CNA 2
inside Shower 2 holding a bottle of Toilet Bowl Cleaner (cleaning solution). HKS stated she was told that
Resident 4 drank and spit out the cleaning solution. HKS stated Resident 4 likes to wander around Station
2.
During an observation in Resident 4's room on 5/15/2024 at 12:14 PM, Resident 4 was observed seated on
the wheelchair about to be assisted for lunch by the facility staff. Resident mumbled and was not able
respond to any questions asked.
During an interview with Licensed Vocational Nurse (LVN 1), on 5/15/2024, at 12:38 PM, LVN 1 stated CNA
2 found Resident 4 in Shower 2 on 5/2/2024 at around 8:30 PM holding a bottle of cleaning solution. LVN 1
stated she was informed by CNA 2 that Resident 4 had a bottle of cleaning solution tilted towards Resident
4's mouth when she found her. LVN 1 stated CNA 2 saw Resident 4 spit something out of her mouth after
Resident 4 was found. LVN 1 stated Resident 4 gets restless and wanders around the facility and needs to
be redirected when the resident wanders. LVN 1 stated the Shower 2 door is usually left open. LVN 1 stated
housekeeping staff store bottles of cleaning solutions in the housekeeping cart of in the locked closet. LVN
1 stated housekeeping staff is not allowed to leave any bottles of cleaning solution in the bathrooms or
showers. LVN 1 stated residents can have a bad reaction and get sick from ingesting cleaning solution.
During an interview with CNA 1, on 5/15/2024, at 1:08 PM, CNA 1 stated, on 5/2/2024, at approximately
8:45 PM, CNA 1 and CNA 2 were getting ready to prepare Resident 4 for bed and found Resident 4 inside
Shower 2. CNA 1 stated she was walking behind CNA 2 when CNA 2 found Resident 4 inside Shower 2
holding a bottle of cleaning solution tilted and pointing towards the resident's mouth. CNA 1 stated CNA 2
pulled Resident 4's wheelchair back and immediately checked Resident 4's mouth for any cleaning solution.
CNA 1 stated the bottle of cleaning solution was left inside Shower 2. CNA 1 stated Resident 4 can get sick
from drinking cleaning solution. CNA 1 stated Resident 4 needs to be supervised for her safety because
she tends to wander into different rooms in the facility.
During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on
5/15/2024, at 1:32 PM, the DON stated she was notified on 5/2/2024 at approximately 10 PM the Resident
4 was seen holding a bottle of cleaning solution inside Shower 2. The DON stated CNA 2 saw Resident 4
spitting after Resident 4 was found. The DON stated Resident 4 possibly wheeled herself into Shower 2
which is located across Resident 4's room. The DON stated Shower 2 door did not have a lock. The DON
stated that based on the facility's investigation, a housekeeping staff left the bottle of cleaning solution in
Shower 2.
During the same interview with the DON and ADON, on 5/15/2024, at 1:32 PM, the DON stated
housekeeping staff is not allowed to leave any cleaning solution around the facility. The DON stated
cleaning solutions should be placed in the locked closet or inside the locked housekeeping cart to prevent
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055153
If continuation sheet
Page 2 of 3
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
055153
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Montebello Care Center
1035 W Beverly Blvd
Montebello, CA 90640
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 0689
Level of Harm - Minimal harm
or potential for actual harm
residents having and access to the cleaning solutions and from accidentally ingesting the cleaning solution.
The DON stated if the cleaning solution is ingested it can cause accidental poisoning, potential harm, a
change in condition, and possible hospitalization for the resident. The DON stated, on 5/2/2024, the facility
staff did not monitor Resident 4's location in the facility and provide redirection when the resident wheeled
herself inside Shower 2.
Residents Affected - Few
A review of the facility's P&P, titled, Storage Areas, Maintenance, revised on 12/2009, indicated,
Maintenance storage areas shall be maintained in a clean and safe manner.
A review of the facility's P&P, titled, Safety and Supervision of Residents, revised on 7/2017, indicated the
following:
Our facility strives to make the environment as free from accident hazards as possible. Resident safety and
supervision and assistance to prevent accidents are facility-wide priorities.
Our individualized, resident-centered approach to safety addresses safety and accident hazards for
individual residents.
The interdisciplinary care team shall analyze information obtained from assessments and observations to
identify any specific accident hazards or risks for individual residents.
The care team shall target interventions to reduce individual risks related to hazards in the environment,
including adequate supervision and assistive devices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055153
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the May 15, 2024 survey of MONTEBELLO CARE CENTER?
This was a inspection survey of MONTEBELLO CARE CENTER on May 15, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MONTEBELLO CARE CENTER on May 15, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.