Montebello Care Center

In the surveyor’s words

From the most serious findings on record at Montebello Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 29, 2023

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). Resident 2, who had behavioral issues, hit Resident 1 on the face and head on [DATE] in Resident 1 and 2's room. The facility did not identify, assess, and implement interventions to address Resident 2's behavior, mood, and cognitive (the ability to clearly think, learn, and remember) status prior to Resident 2 hitting Resident 1 on the face. […]

• Immediate jeopardy, isolatedF658May 29, 2023

  Based on interview and record review, the facility failed to provide treatment and services for one of two sampled Residents (Resident 1), after being hit on the face and head, in accordance with current professional standard of practice by failing to: 1. Conduct a neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face… […]

• Actual harm, isolatedF760Mar 1, 2023

  Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication error (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). On 2/26/23, the licensed nurse (RN1) did not properly check and identify the resident prior to administering medications. RN1 erroneously administered eight (8) medications to Resident 1 belonging to Resident 2. This deficient practice resulted in Resident 1 to experience adverse effects that included nausea, vomiting, dizziness, and malaise (feeling of being unwell and feeling tired). […]

• No harm, potential for more than minimal, widespreadF880Apr 25, 2024

  Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility staff failed to: 1. Wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) when entering an Enhanced Standard Precaution (reducing transmission of organisms through health provider with the use of gown and gloves when caring for the resident) room. This deficient practice has the potential to spread infection to other residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was fully implemented. […]

• No harm, potential for more than minimal, patternF550May 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 3, 23 and 71) reviewed for dignity were treated with respect and dignity in accordance with the facility's policy and procedure (P&P) when: Resident 3's indwelling catheter (a hollow tube inserted into the bladder [a hollow, balloon-shaped muscular organ located in your lower pelvis. Its primary job is to collect and store urine made by your kidneys until it is ready to be released from the body] to drain or collect urine) collection bag (ICCB) was not fully covered with a dignity bag. The dignity bag was covering the top half of the ICCB exposing the urine at the bottom of the ICCB. […]