Health 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). Page 1 of 6 055105 055105 03/03/2025 Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Progress Notes, dated 1/26/2025 at 1:14 PM, the Progress Notes indicated Resident 1 was transferred to a GACH via ambulance due to an unwitnessed fall with a right upper eyelid laceration and left hip and sacral pain. During a review of Resident 1's Fall Risk Assessment, dated 2/3/2025, the assessment indicated Resident 1 was at high risk for potential falls. During a review of Resident 1's GACH discharge instructions, dated [DATE] at 1:15 PM, the discharge instructions indicated a diagnosis of left iliac (the largest and uppermost bone of the hip) fracture. During a review of Resident 1's Progress Notes, dated 2/3/2025 at 9:38 PM, the Progress Notes indicated Resident 1 was admitted back to the facility around 4 PM with a left iliac fracture. During an interview on 3/3/2025 at 11:09 AM, the Registered Nurse (RN) stated Resident 1 fell on 1/26/2025. During an interview on 3/3/2025 at 1:09 PM, the RN stated when the resident falls and sustains a fracture, it is considered an unusual occurrence. During a concurrent record review and interview on 3/3/2025 at 2 PM with the Director of Nursing (DON), the facility's Policy and Procedure titled, Unusual Occurrence Reporting, revised 2/2025 was reviewed. The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. The DON stated if a resident has an unwitnessed fall, the facility will need to report to SA as indicated in the P&P. During an interview on 3/3/2025 at 2:16 PM, the RN stated the facility found out about Resident 1's fracture was when the resident was readmitted to the facility on [DATE]. During an interview on 3/3/2025 at 2:40 PM, the DON stated Resident 1's fall needs to be reported to SA as an unusual occurrence since the fall resulted to the reisdent sustained a fracture. During a review of the facility's P&P titled, Unusual Occurrence Reporting, revised 2/2025, the P&P indicated a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency as required by federal and state regulations. 055105 Page 2 of 6 055105 03/03/2025 Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan for one of two sampled residents (Resident 1) by not ensuring a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was placed at Resident 1's bedside after an unwitnessed fall on 1/26/2025 wherein the resident sustained a fracture (the cracking or breaking of the bone). This deficient practice has the potential for Resident 1 to have further falls with injury. 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 diagnoses of 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 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 on right upper eyelid and left hip and sacral pain. During a review of Resident 1's Care Plan with focus At risk for falls, dated 1/26/2025, the Care Plan indicated an intervention of placing a floor mat at Resident 1's bedside. During a review of Resident 1's Fall Risk Assessment, dated 2/3/2025, the Care Plan indicated Resident 1 was at high risk for potential falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, the MDS indicated resident is 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. Resident 1 is 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 concurrent observation and interview on 3/3/2025 at 1:20 PM with Registered Nurse (RN) 1, Resident 1 was observed sleeping in bed with floor mat placed under the bed. RN 1 stated it is not okay because the resident can fall and get hurt. RN 1 also stated the facility is not following Resident 1's plan of care for risk for fall. During a concurrent record review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Plans, revised 2/2025, and interview on 3/3/2025 at 2pm with the Director of Nursing (DON), the P&P indicated the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) with the 055105 Page 3 of 6 055105 03/03/2025 Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776

F 0656 resident/responsible party develops and implements a comprehensive, person-centered care plan for each resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055105 Page 4 of 6 055105 03/03/2025 Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776

F 0880 Provide and implement an infection prevention and control program. 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 ensure the facility staff performs hand hygiene (an action of hand cleansing such as with soap and water or applying alcohol based handrub to the surface of the hands) according to the facility's policy for one (1) of 4 sampled residents. Residents Affected - Few This deficient practice had the potential to spread infection to staff and residents. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of chronic kidney disease (CKD - progressive damage and loss of function in the kidneys), urinary tract infection (UTI - an infection in the bladder/urinary tract), and diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels). During a review of Resident 3's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 3 is 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 eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 3/3/2025 at 10:45 AM, Activities 1 was observed feeding Resident 3 with bare hands. Activities 1 was then observed touching Resident 1's hair and ears when talking to Resident 1. After touching Resident 1, Activities 1 did not perform hand hygiene. and then went to touch Resident 4's shoulder area and wheelchair. Activities 1 then went back to assist Resident 1 with meals and did not perform hand hygiene. Activities 1 stated he should have performed hand hygiene before and after each resident to prevent the spread of infection. During an interview on 3/3/2025 at 11 AM, Activities Director (AD) stated Activities 1 is not supposed to feed Resident 3 with his bare hands and should have worn gloves to prevent the spread of infection. AD also stated Activities 1 should have perform hand hygiene before and after assisting with each Resident 1 and Resident 4. During an interview on 3/3/2025 at 12:17 PM, Infection Preventionist Nurse (IPN) stated staff should perform hand hygiene before and after feeding/touching residents. IPN also stated Activities 1 should have performed hand hygiene and use a glove when feeding Resident 3. During a review of the facilities Policy and Procedure (P&P), titled Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated hand hygiene is indicated: 1. Immediately before touching a resident. 055105 Page 5 of 6 055105 03/03/2025 Royal Vista Care Center 909 W. Santa Anita Ave San Gabriel, CA 91776

F 0880 2. Level of Harm - Minimal harm or potential for actual harm After touching a resident. 3. Residents Affected - Few After touching a resident's environment. The P&P also indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 055105 Page 6 of 6