Health inspection·July 28, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 have an effective pest control program to ensure the facility was free from pests (roaches).This failure had the potential for the spread of harmful bacteria (tiny cells that can cause infections and illnesses) and infection to residents in the facility.Findings:During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a long term lung condition that makes it hard to breathe), hypertension (high blood pressure), epilepsy (a brain disorder that causes recurring seizures), old myocardial infarction (a heart attack sometime in the past), heart failure (heart muscle doesn't pump blood as well as it should), atherosclerotic heart disease of native coronary artery( buildup of fats, cholesterol in the artery walls) unspecified psychosis(symptoms that affect the mind, where there has been some loss of contact with reality), and Type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing)and malignant neoplasm of right and left bronchus and lung).During a review of Resident 4's Minimum Data Set (MDS- a standardized assessment tool) dated 7/2/2025, the MDS indicated Resident 4 had intact cognition (ability to think and reason).During an observation of the facility nurses' station on 7/19/25 at 2:15p.m. with Registered Nurse (RN) 1, a large brown bug approximately 2 inches in length with an oval shaped body, flat head, two long antennas, and multiple legs was observed crawling on the floor away from the nurses' station. RN 1 was asked to identify insect and stated it was a cockroach. RN 1stated having cockroaches in the facility was an issue with cleanliness and residents could fall ill from the bacteria roaches carried. RN1 stated cockroaches in the facility was not sanitary. and was a pest control issue and infection control issue.During an interview on 7/28/25 at 2:24 p.m. with Resident 4, Resident 4 stated, I see cockroaches every day and it's not right. It needs to be cleaned right away; it means it's not a clean environment. It's possible that I can get sick from there being roaches.During an interview on 7/28/25 at 2:27p.m., the Administrator stated, the pest control company was at the facility on 7/3/25. The administrator stated the pest control company would go to the facility monthly and when needed. During an interview on 7/28/25 at 2:27p.m., the Interim (temporary) Director of Nursing (IDON) stated, cockroaches in the facility could cause the residents to get sick, develop nausea, vomiting, diarrhea, and residents could end up in the hospital. The IDON stated all residents could be negatively affected, especially the residents with weakened immune systems.During a review of the facility's policy and procedures (P&P) titled Pest Control revised in May 2021, the policy indicated This facility maintains an on-going pest control program to ensure that the building is kept free of insects.During a review of the facility's P&P titled Infection Prevention and Control Committee revised in July 2021, the policy indicated Provide facility guidelines for a safe and sanitary environment. The policy further indicated, Assist in reviewing food handling practices, laundry practices, waste Residents Affected - Some (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: 055538 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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)