Health inspection·January 9, 2026

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 an injury of unknown origin for one of ten sampled residents (Resident 2) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results, in accordance with facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, damage to brain tissue caused by loss of blood flow to a part of the brain). During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 4/19/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on others for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and chair/bed-to-chair transfers. During a review of Resident 2's bilateral hip X-ray results, dated 12/21/2025 and timed at 9:14 am, the X-ray results indicated Resident 2 had a suspected acute right femur fracture. During a review of Resident 2's Change In Condition Evaluation (CIC), dated 12/21/2025 and timed at 1:56 pm, the CIC indicated Resident 2's bilateral hip X-ray results indicated Resident 2 had a suspected right femur fracture and Resident 2's primary physician recommended Resident 2 to be transferred to GACH 1 for further evaluation. During a review of Resident 2's Nurses Note (NN), dated 12/21/2025 and timed at 4:30 pm, the NN indicated Resident 2 was picked up by an ambulance and transferred out to GACH 1 at 4:20 pm. During a review of Resident 2's GACH 1 right hip X-ray, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. During an interview on 1/9/2026 at 3:30 pm with the Director of Nursing (DON), the DON stated the facility did not do an investigation to determine how Resident 2 sustained the right femur fracture and did not report Resident 2's injury of unknown origin (right femur fracture) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results. The DON stated the facility did not follow their policy on investigating injuries of unknown origin. During a review of the facility's policy and procedure (P&P) tiled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, (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 4 Event ID: 055817 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 055817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monte Vista Healthcare Center 802 Buena Vista Street Duarte, CA 91010 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)