Health inspection·June 27, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (1) of 2 sampled residents (Resident 1) who was unable to carry out Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene. Residents Affected - Few This deficient practice resulted in Resident 1's fingernails being untrimmed with sharp edges which potentially resulted in the pea size bruise on the inner corner of the resident's left eye and scratches measuring 1/4 to 1 inch to the resident's right forehead. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included autistic disorder (a complex developmental condition involving persistent challenges with social communication, restricted interests and repetitive behavior) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/17/2025, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with toileting, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral and personal hygiene and upper body dressing. During an observation on 6/27/2025 at 12:17 PM, Resident 1 was observed with a pea size bruise on the inner corner of the left eye and scratches on the resident's right forehead measuring approximately 1/4 to 1 inch. Resident 1 was also observed with untrimmed fingernails on both the resident's left and right hands with some sharp edges. During an interview with Certified Nursing Assistant 1 (CNA 1) on 6/27/2025 at 12:24 PM, CNA 1 also stated nail care was part of the CAN's job responsibilities and Resident 1's fingernails should be assessed daily to ensure the resident's fingernails are clean and trimmed. During an interview on 6/27/2025 at 1:50 PM, the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's fingernails should have been assessed and trimmed to ensure the resident would not continue injuring himself from the scratching. LVN 1 also stated Resident 1's fingernails should have been care (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 06/27/2025 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)