Health inspection·August 30, 2024

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 8/23/2024, indicated resident is severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. The MDS also indicated resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Weight and Vitals Summary, dated 6/5/2024, indicated resident's weight was 165 lbs. During a review of Resident 1's Weight and Vitals Summary, dated 7/3/2024, indicated resident's weight was 159 lbs. During a review of Resident 1's Meal intake dated 6/30/2024-7/15/2024, indicated on: 1. 7/3/2024 ate 50% of her lunch and dinner. 2. 7/5/2024 ate 50% of her breakfast and lunch. 3. 7/6/2024 ate 0% her breakfast and lunch. 4. 7/7/2024 at 50% of her breakfast and 25% of her dinner 5. 7/8/2024 Refused her breakfast and lunch and ate 50% of her dinner. 6. 7/9/2024 ate 25% of her breakfast and lunch and refused her dinner. During a review of Resident 1's COC Evaluation, dated 7/10/2024, indicated resident is having functional decline, general weakness poor meal intake of 0-50%. The COC Evaluation also indicated resident was chewing food and spitting it out. During a review of Resident 1's GACH's Emergency Department Record, dated 7/10/2024, indicated admitting diagnosis of dehydration, anorexia, and general weakness and resident is at risk for malnutrition. During an interview on 8/29/2024 at 1:50 PM, Registered Dietician stated she was not made aware of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 2 of 4 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 08/30/2024 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 0692 Resident 1's weight loss on 7/3/2024. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/29/2024 at 2:12 PM, Assistant Director of Nursing (ADON) stated the Registered Dietician (RD) was not made aware of Resident 1's weight loss on 7/3/2024 and should have been informed. Residents Affected - Some During a concurrent record review of Resident 1's medical records and interview on 8/30/2024 at 10:26 AM, ADON stated on 7/10/2024, Resident 1's primary physician was made aware of Resident 1's weight loss of 6 lbs. taken on 7/3/2024. The ADON stated, Resident 1's primary physician should have been informed of the resident's COC of weight loss noted on 7/3/2024 as soon as possible but the primary physician was not made aware until 7/10/2024 and it was too late that Resident 1 needed to be sent to GACH. During the same concurrent interview with ADON on 8/30/2024 at 10:26 AM and record review of Resident 1's meal intake from 6/30/2024 to 7/15/2024, ADON stated if the resident was eating 50% or less the Certified Nursing Assistant (CNA) should inform the charge nurse and the charge nurse should inform the resident's primary physician and RD. ADON stated, Resident 1 had 50 % or less meal intake on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024. ADON stated, there was no documented evidence that Resident 1's primary physician and/ or RD was notified regarding resident's meal intake of 50% or below. During a concurrent record review of Resident 1's Care Plans, dated 7/3/2024- 7/10/2024, and interview on 8/30/2024 at 11 AM, the Director of Nursing (DON) stated the facility did not create a resident centered care plan but should have a care plan to address Resident 1's poor meal intake that was noted on 7/3/2024 and poor meal intake noted on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024. During the same concurrent record review of Resident 1's medical records, dated 7/3/2024-7/9/2024, and interview on 8/30/2024 at 11 AM, the DON stated there was no documented evidence that Resident 1's primary physician and RD was made aware of Resident 1's weight loss on 7/3/2024. The DON stated a if a resident was eating 50% or less for two meals including weight loss of 6 lbs. within a span of 28 days, it is considered COC and should be included the facility's policy for Change of Condition. The DON also stated a COC should have been done between the dates from 7/3/2024 to 7/9/2024 when Resident 1 was noted to be eating 50% or less of two meals and weight loss of 6 lbs. on 7/3/2024. During an interview on 8/30/2024 at 11:30 AM, the DON stated Resident 1's care plan, dated 7/3/20247/9/2024, did not include goals or interventions to address Resident 1's weight loss of 6 lbs. on 7/3/2024 and no care plan initiated for Resident 1's poor meal intake noted from 7/3/2024 to 7/9/2024 which can put the resident at risk for nutritional deficiency or malnutrition. The DON also stated there was no Interdisciplinary Team (IDT; brings together knowledge form different health care disciplines to help residents receive the care they need) meeting conducted regarding Resident 1's weight loss on 7/3/2024 and poor meal intake that was noted from 7/3/2024 until 7/9/2024. During an interview on 8/30/2024 at 12:40 PM, Certified Nursing Assistant 2 (CNA 2) stated she will only report to the licensed nurse if the resident was eating 25% or less. During an interview on 8/30/2024 at 12:50 PM, CNA 1 stated she will only report to the licensed nurse if the resident was eating 25% or less. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 3 of 4 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 08/30/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/30/2024 at 2:20 PM, primary physician stated she was made aware of Resident 1's poor meal intake when she gave an order for the resident to go to the hospital on 7/10/2024 and was not made aware from 7/3/2024 to 7/9/2024. During a review of the facility's Policy and Procedure (P&P) Charting and Documentation, revised July 2017, indicated changes in resident's condition is to be documented in the resident's medical record. The policy also indicated documentation will include the assessment data or any unusual findings and whether the resident refused the procedure/treatment. During a review of the facility's P&P titled Weight Management, dated 8/25/2021, indicated the facility IDT collaborates for determining the need for initiation or discontinuation of weights other than weekly or ordered by physician. The P&P also indicated that RD will be responsible for determining the desirable weight range or usual body weight range. During a review of the facility's P&P titled Notification of Change in Condition, dated 8/25/2021, indicated to ensure physicians are informed of changes in the resident's condition. During a review of the facility's P&P titled Interdisciplinary Team Care Plan, dated 8/25/2021, indicated the care plan is based on the resident's assessment and developed by an interdisciplinary Team to meet the needs of the resident. During a review of the facility's P&P Care Plan Comprehensive, dated 8/25/2021, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) needs shall be developed for each resident. The policy also indicated each resident's comprehensive care plan is designed but not limited to incorporate identified problem areas and incorporate risk and contributing factors associated with identified problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 4 of 4