Inspection·March 13, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility exit doors and hallways were free from obstruction and clutter. This deficient practice had the potential to place residents and facility staff at risk for accidents, such as tripping and falling, and impede or hinder immediate evacuation from the facility in cases of emergency. Findings: During an observation of the facility on 3/13/2025 at 7:36 AM, one wheelchair was observed on the left side of the hallway and one wheelchair was observed on the right side of the hallway blocking the exit doors by rooms [ROOM NUMBERS]. During an observation of the facility on 3/13/2025 at 7:38 AM, one wheelchair was observed on the right side of the hallway blocking the exit doors by rooms [ROOM NUMBERS]. During an observation of the facility on 3/13/2025 at 7:40 AM, one wheelchair was observed on the left side of the wall and two soiled linen bins were observed on the right side of the wall blocking the exit doors by rooms [ROOM NUMBERS]. During an observation of the facility on 3/13/2025 at 7:42 AM, one wheelchair was observed placed on the left side of the wall and another wheelchair was placed on the right side of the wall in front of the exit doors. During an observation of the facility on 3/13/2025 at 7:44 AM, by the hallway before the back dining room, a bed was observed placed on the left side of the wall and a wheelchair, 2 drawer carts and a linen cart were observed placed on the right side of the wall blocking the exit doors. During a concurrent observation and interview on 3/13/2025 at 7:52 AM with the Interim Director of Nursing (IDON), the five exit doors with wheelchairs, bed, soiled linen bins, drawer carts and equipment were observed. The IDON stated that any object placed near the exit doors should be three feet (ft-a unit of length, equal to 12 inches) away from the exit doors so they remain unobstructed. The IDON stated if the exit doors were obstructed, residents and staff could not safely exit the facility. The IDON stated that only one side of the hallway should be used to place wheelchairs, carts, bins or any equipment. (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 03/13/2025 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)