Inspection·January 29, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as a high risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the Director of Activities (DOA) wheeled Resident 1 outside of the activity room to take care of other residents and left Resident 1 unattended while sitting in a wheelchair (WC) at the hallway (outside the activity room). This deficient practice resulted in Resident 1 fell in the hallway outside the activity room on 1/18/2025 around 11:13 AM. Resident 1 sustained redness on the right side of resident's forehead. On 1/24/2025 (6 days after the fall), Resident 1 complained of pain on the resident's right ribs (slender curved bones protecting the lungs). Resident 1 underwent a Xray (a quick, painless test that captures images of the inside of the body) on 1/25/2025 and the result showed that Resident 1 had a fracture (a break in a bone) on the resident's eighth (8th) and ninth (9th) ribs. Findings: During a review of Resident 1's admission Record, it indicated the resident was admitted to the facility on [DATE] with diagnoses that included: dementia, cerebral infarction, lack of coordination and repeated falls. During a review of Resident 1's admission Fall Risk Assessment (AFRA) dated 1/17/2025, it indicated, Resident 1 is chair bound (unable to walk and dependent on a chair/ wheelchair to move around) and has a high risk for potential falls. During a review of Resident 1's Care Plan (CP) dated 1/17/2025, the CP indicated Resident 1 was at risk for falls due to history of falls. The CP did not indicate interventions such as facility staff actions or strategies to prevent resident from falling while the resident is in the wheelchair, such as monitoring and/ or supervising the reisdent while in wheelchair. During a review of Resident 1's Change of Condition (CoC) dated 1/18/2025 at 11:13 AM, it indicated Resident 1 fell outside the activity room while trying to turn his WC and the resident's right hand slipped causing the resident to fall on the floor. The COC also indicated the resident was observed having redness to the right side of the forehead. During a review of Resident 1's CoC dated 1/24/2025 at 7:44 PM, COC indicated the resident has (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 3 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 01/29/2025 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)