Health inspection·February 17, 2026

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated 4/2021, for one of three sampled residents (Resident 3) on 1/30/2026 by failing to report Resident 3's allegation of abuse within two hours and failing to remove Certified Nursing Assistant (CNA) 1 from resident contact immediately after Resident 3 made an allegation of abuse involving CNA 1.These deficient practices had the potential for Resident 3 to feel unsafe and for Resident 3 to be subjected to abuse.Findings:During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 3's Minimum Data Set (MDS resident assessment tool), dated 2/5/2026, the MDS indicated Resident 3 had moderately impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort to complete activity) on staff for toileting hygiene and bathing.During a review of Resident 3's Progress Notes (PN), dated 1/30/2026 and timed at 1:55 PM, the PN indicated two CNAs reported Resident 3 had complained that a CNA (unidentified) grabbed Resident 3's upper arm resulting in a small area of redness. The PN further indicated the two CNAs stated the redness on Resident 3's arm was present before Resident 3 was assisted by the CNAs.During a review of Resident 3's Change in Condition Evaluation (COC), dated 1/30/2026 and timed at 2:30 PM, the COC indicated a CNA grabbed Resident 3's upper arm, resulting in a small area of redness. The COC further indicated Resident 3's mental status was assessed, and Resident 3 did not know the current location, situation and date/time.During a review of Resident 3's Post-Event Review -V2 (PER), dated 1/30/2026 and timed at 6 PM, the PER indicated Resident 3 alleged a Certified Nurse Assistant (CNA) scratched or ripped Resident 3's arm. The PER indicated Resident 3 had a diagnosis of dementia and an active UTI and provided inconsistent statements to staff consistent with dementia and UTI related delirium.During an interview on 2/17/2026 at 2:12 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 worked as a charge nurse during the 7 am to 3 PM shift on 1/30/2026. LVN 1 stated Resident 3 was generally forgetful, anxious and would repeatedly ask for things even after it was already provided to Resident 3. LVN 1 stated CNA 1 reported to LVN 1 that Resident 3 alleged CNA 1 had grabbed Resident 3's arm while changing Resident 3's soiled brief. LVN 1 then went to Resident 3's room to assess Resident 3's skin and found no new marks or discoloration on Resident 3's arms. Afterwards, LVN 1 reported the incident to the Infection Prevention Nurse (IPN) and LVN 1 began documenting the incident. LVN 1 stated Resident 3's PN dated 1/30/2026 at 1:55 PM was correct and the incident happened around that time.During an interview on 2/17/2026 at 2:37 PM with the IPN, the IPN stated on 1/30/2026 CNA 1 had reported the incident with Resident 3 to the IPN. The IPN instructed CNA 1 to report the incident to LVN 1. The IPN went into Resident 3's room to assess Resident 3's skin and the IPN did not Residents Affected - Few (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: 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 02/17/2026 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)