Health inspection·May 20, 2025

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 interview and record review, the facility failed to develop an individualized care plan for one of three sampled residents (Residents 1) after Resident 1 had a change of condition, exhibited behavior of kneeling and placing self on floor, and was a high risk of falls. This failure had the potential to result in Residents 1's needs not being met, unidentified interventions and falls for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) fracture (broken bone) of the right ulna (long bone in the forearm) and unsteadiness on feet. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 1 had severe (serious) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). The MDS indicated Resident 1 was dependent (staff does all the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and toileting hygiene. During a review of Resident 1's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 1 was a high fall risk for falls. During a review of Resident 1's care plan dated 4/23/2025, the care plan indicated Resident 1 was at risk for falls related to medication use, incontinence (unable to voluntarily control urination or defecation), impaired physical function and cognition and disease process. The care plan interventions indicated to anticipate and meet the resident's needs. The care plan did not specify the type of supervision or monitoring Resident 1 needed. During a review of Resident 1's SBAR (Situation, Background Assessment, Recommendation- a communication tool used by healthcare workers when there is a change in condition among the residents) dated 4/24/2025, the SBAR indicated Resident 1 had episodes of placing self on floor. The change of condition also indicated to monitor Resident 1's behaviors. During a review of Resident 1's care plan dated 4/24/2025, the care plan indicated Resident 1 had episodes of kneeling/placing self on the floor. The care plan goal indicated Resident 1 would be free (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: 555112 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 555112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Rancho Vista Health Care Center 8925 Mines Avenue Pico Rivera, CA 90660 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)