Health inspection·August 1, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment by failing to prevent the accumulation of dust and lint, and dispose dead cockroaches found in the facility's laundry room. This deficient practice had a high potential to encourage pest activity and infection. Findings: During a concurrent observation of the facility's laundry room and interview with maintenance assistant (MA) on 8/1/2024 at 10:58 AM, two cockroach traps were observed behind the two dryer machines. The surrounding area where the cockroach traps were located was observed dusty and with lint accumulation. MA stated that these cockroach traps appear old. MA stated the cockroach traps were covered with lint. MA stated that one cockroach trap had six (6) dead insects and the other cockroach trap had five (5) dead insects. MA stated, These insects are not cockroaches, these are American water bugs. MA stated he did not know when these cockroach traps were placed in the laundry room. MA verified that these cockroach traps were not dated. MA stated that he did not know when to dispose the dead insects and when to change the traps. During an interview with laundry staff 1 (LS 1) on 8/1/2024 at 3:20 PM, LS 1 stated, I had seen cockroach traps in the laundry room, behind the dryer machines, with dead cockroaches in it for few days now. LS 1 stated that she did not know when or who needs to discard the cockroach trap with the dead cockroach in it. LS 1 added that cockroaches are dirty and should not be in the facility. During an interview with Infection Preventionist Nurse (IPN) on 8/1/2024 at 3:30 PM, IPN stated that having a dead or alive cockroach was unsanitary. IPN stated that cockroaches could potentially go into the clean linen carts, which were distributed throughout the facility and can cause residents to get sick. During an interview with the Assistant Administrator (AA) on 8/1/2024 at 4 PM, AA stated cockroach traps were placed by pest control company to monitor cockroach activity in the laundry room. AA stated that facility was not given instructions when to dispose the cockroach traps with dead cockroaches. AA was unable to provide documented evidence when the cockroach traps were placed in the laundry room. AA stated, All I know is the pest control company wanted to monitor cockroach activity by monthly basis, and that is when pest control will determine the treatment for the area. During a concurrent record review of the facility's Policy and Procedure (P&P) titled, Pest Control, revised in May 2008, and interview with the Director of Nursing (DON) on 8/1/2024 at 4:30 PM, the (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: 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 08/01/2024 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)