Inspection·March 3, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the State Agency (SA) within 24 hours after an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for one of two sampled residents (Resident 1) when the facility was made aware on 2/3/2025 of Resident 1's sustained a fracture (complete or partial break in the bone) from a fall in accordance with the facility's policy and procedure titled Unusual Occurrence Reporting. This deficient practice had a potential for ongoing/ another unusual occurrence for Resident 1 or other residents in the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoseof dementia (a progressive state of decline in mental abilities), muscle weakness and fracture of the left ilium (the large broad bone forming the upper part of the pelvis). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, the MDS indicated resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with oral hygiene and personal hygiene. The MDS indicated Resident 1 was also dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. During a review of Resident 1's Fall Risk Assessment, dated 12/3/2024, the assessment indicated Resident 1 was at high risk for potential falls. During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition [COC] among the residents)/COC, dated 1/26/2025, the SBAR/COC indicated an unwitnessed fall with skin laceration (skin wound) on right upper eyelid and left hip and sacral (a large triangular bone at the base of the spine) pain. The SBAR/COC also indicated Resident 1 was found on the floor, complained of pain in the left hip and sacral area and was transferred to a general acute care hospital (GACH). (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 6 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 03/03/2025 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)