Inspection·October 24, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the medical records for one of one sampled resident (Resident 1) within 48 hours (excluding weekends and holidays) from when the written request was received from the resident's representative on 10/3/2024. This deficient practice has resulted in the delay of access to Resident 1's medical records in a timely manner. 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 transferred to the emergency room (ER) in General Acute Hospital (GACH) on 9/18/2024 via ambulance. During a review of Resident 1's History and Physical (H&P), dated 11/16/2022, with diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and generalized weakness. The H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool), dated 7/5/2024, the MDS indicated Resident 1 had severe 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 of the effort, resident does none of the effort to complete the activity) eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/ taking off footwear, personal hygiene, roll left and right, chair/ bed - to -chair transfer and tub/shower transfer. During a review of the authorization for the release of Resident 1's medical records dated 9/27/2024, indicated the facility received a request from Resident 1's representative to provide a copy of Resident 1's medical records on 10/3/2024 via electronic mail (email). During a review of the undated Facility's Authorization of Release of Information Form, it did not indicate that facility released Resident 1's records from 10/3/2024 to 10/24/2024. During an interview of Medical Records Director (MRD) on 10/24/2024, at 9:29 AM, MRD stated, If the resident or family made a request for the copy of the whole medical records. They can pick up the (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: 055105 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 055105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776 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)