Health inspection·July 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reconciled from the discharge medication list was not acceptable as it will affect the residents' health and safety and residents are put at risk for experiencing complications for not having received the medications. Resident 6's BPH symptoms could end up getting worse and affect Resident 6's overall health. The DON stated RN 1 could not explain why the terazosin order was not reconciled in Resident 6's Order Summary. The DON stated there were 87 doses of Terazosin that was not given to Resident 6, from 1/28/2025 to 4/24/2025 because the resident's discharge medication list for GACH 2 was not reconciled correctly. During a concurrent interview and record review on 7/18/2025 at 10 AM with Resident 6's attending physician (MD), the External Facility Discharge Medication List from GACH 2 was reviewed. The discharge medication list from GACH 2 reflected order for terazosin to give once a day. The MD validated that terazosin was not reconciled and was not given to Resident 6 during the resident's stay in the facility from 1/28/2025 to 4/24/2025. The MD stated the terazosin was for Resident 6's BPH and resident did not receive this medication. During a review of the facility's Policy and Procedure (P&P), titled Reconciliation of Medication on Admission, revised 1/5/2025, the P&P indicated the purpose of the P&P is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The P&P also indicated, medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. In addition, the P&P indicated, medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. The P&P indicated steps includes: Verify and clarify medication list with the physician Transcribe verified orders to point click care (PCC-a cloud-based healthcare technology platform that focuses on connecting care providers, services, and financial operations within the senior care and long-term care sectors) under physician orders Event ID: Facility ID: 055153 If continuation sheet Page 2 of 5 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 07/18/2025 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)

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 on interview and record review, the facility failed to prevent accidents to one of four (Resident 1) sampled residents who was identified at risk for falls and had a history of falls in accordance with the facility's policy and procedure (P&P) titled, Fall Management by failing to:1. Ensure adequate supervision of Resident 1 was provided to prevent accidents and injury on 7/16/2025.2. Create a comprehensive resident - centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for Resident 1's long term care plan with focus on Resident 1's risk for fall/injury which includes intervention to supervise the resident every hour from 4/1/2025 to 7/16/2025. This deficient practice resulted in Resident 1 found on the floor near the Nurse's Station and the resident lying on her right side next to her on 7/16/2025 at 4:45 AM. Resident 1 was noted to have a small skin tear on the right temple (the area on the side of the head, just above the cheekbone and below the hairline) with minimal bleeding.Findings: During a review of Resident 1's admission Record, the admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral/personal hygiene, and upper/lower body dressing. Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer. During a review of Resident 1's Nursing Documentation Evaluation, dated 3/23/2025, the Nursing Documentation Evaluation form indicated Resident 1's Fall Risk factor included disorientation, confusion, and visual impairment. Resident 1's Nursing Documentation Evaluation form indicated fall risk indicators were identified for Resident 1. During a review of Resident 1's Interdisciplinary Care Conference (IDT- a meeting where healthcare professionals from different disciplines collaborate to develop or review a resident's care plan), dated 7/16/2025, the IDT indicated, on 7/16/2025 at 4:45 AM, Resident is observed on right side lying position next to her wheelchair. A small skin tear is noted to the right temple with minimal bleeding observed. During an interview, on 7/18/2025, at 11:27 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was at risk for falls because the resident always tried to jump and move out of bed. CNA 1 stated CNA 1 did not know if Resident 1 had a history of falls in the facility. During an interview, on 7/18/2025, at 12:04 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was assigned to Resident 1 the morning of 7/16/2025 when Resident 1 had a fall. LVN 1 stated Resident 1 was a fall risk and had a history of falls. LVN 1 stated, at around 4 AM, on 7/16/2025, Resident 1 woke up and was restless and anxious in bed. LVN 1 stated CNA 2 placed Resident 1 on the resident wheelchair and wheeled Resident 1 to the Nurse's Station. LVN 1 stated, at around 4:45 AM, LVN 1 was notified by Housekeeping 1 (HSK 1) that HSK 1 found Resident 1 on the floor in the Nurse's Station. LVN 1 stated Resident 1 was found lying on her right side in the Nurse's Station. LVN 1 stated Resident 1 had discoloration and skin tear on the resident's right temporal area. During an interview, on 7/18/2025, at 12:24 PM, with HSK 1, HSK 1 stated, on 7/16/2025 at around 4:30 AM, HSK 1 passed by the Nurse's Station to get the broom and saw Resident 1 sitting on her wheelchair with CNA 2 and when she returned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 3 of 5 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 07/18/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back to the Nurse's Station, she observed Resident 1 leaning towards the right side of the resident wheelchair and did not see CNA 2 or other facility staff at the Nurse's Station. HSK 1 stated HSK 1 informed LVN 1 to check on Resident 1 because the resident could fall and when HSK1 returned to the Nurse's Station, HSK1 found Resident 1 on the floor. HSK 1 stated Resident 1 was alone in the Nurse's Station when HSK1 found Resident 1 on the floor. During a concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the Director of Nursing (DON), Resident 1's long term care plan with focus on Resident 1's risk for falls with risk factors including the resident's physical behavior observed by staff of scooting (sliding in a sitting position) from her low bed onto the fall mat, revised on 3/23/2025, was reviewed. The DON stated Resident 1's care plan intervention for resident safety check every hour for proper positioning, and to address and anticipate resident's needs was cancelled on 3/23/2025. During the same concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the DON, Resident 1's long term care plan with focus on Resident 1's risk for fall/injury dated 4/1/2025 was reviewed. The DON stated Resident 1 has fallen in the facility at least three times from 7/30/2024 to 1/28/2025 and that is the reason why Resident 1 cannot be left unsupervised especially when the resident is in the wheelchair. The DON stated Resident 1 had a behavior of scooting and swinging her legs. The DON stated, at approximately 4:30 AM, on 7/16/2025, HKS 1 walked by the Nurse's Station and observed Resident 1 leaning towards the right side while sitting in the wheelchair at the Nurse's Station. The DON stated CNA 2 should not have left Resident 1 unsupervised on 7/16/2025. The DON stated Resident 1 sustained a skin tear on the resident's right temple. The DON stated facility staff should monitor Resident 1's safety every hour due to the resident's history of falls. The DON stated Resident 1's long term care plan with a focus on Resident 1's risk for fall/injury, dated 4/1/2025, did not include monitoring Resident 1's safety every hour and it should be included. The DON also stated, monitoring of Resident 1's safety every hour was included in Resident 1's previous care plan for at risk for fall that was cancelled on 3/23/2025 and it should have been carried over/ added in Resident 1's care plan for risk for fall/injury. The DON stated there was no intervention in Resident 1's fall care plan for her scooting behavior. The DON stated Resident 1's care plan for risk for fall/injury was not and should have been resident-centered given Resident 1's history of falls and scooting behavior. During an interview, on 7/18/2025, at 2:36 PM, with Physical Therapist 1 (PT 1), PT 1 stated Resident 1 was not cognitively intact and had a history of restlessness. PT 1 stated Resident 1 was dependent with chair repositioning PT 1 stated supervision by facility staff was necessary for Resident 1 while she was on her wheelchair. During a review of the facility's P&P titled, Fall Management, dated 5/26/2021, the P&P indicated the purpose of the policy is to reduce risk for falls and minimize the actual occurrence of falls. The P&P indicated, under the procedure, the following:1. Identify patient's fall risk by reviewing the Nursing Documentation.2. Develop individualized plan of care.3. Review and revise care plan as indicated.4. If patient falls: update care plan to reflect new interventions. During a review of the facility's P&P, titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Each resident's comprehensive care plan is designed to:o Build on the Resident's individualized needs, strengths, preferenceso Identify the professional services that are responsible for each element of careo Reflect currently recognized professional standards of practice for problem areas and conditions Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 4 of 5 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 07/18/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm rather than addressing only symptoms or triggers. The Interdisciplinary Team is responsible for evaluation and updating care plans when there has been a significant change in the residents' condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055153 If continuation sheet Page 5 of 5