Health inspection·December 8, 2023

F 0580 showering/bathing self. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/8/2023 at 10:55 am, with Resident 4, Resident 4 stated on 10/18/2023, Resident 4 was at an eight (8, severe pain) out of ten on the NRS. Resident 4 stated on 10/18/2023 at 4 am, Resident 4 received one (1) dose of Norco (Hydrocodone-acetaminophen, medication used to treat moderate pain). Resident 4 stated Resident 4 requested for Resident 4's next dose of pain medication and the nurse (unable to identify) told Resident 4 the medication was not ready. Resident 4 stated Resident 4's pain was unmanageable (no relief) and no one in the facility helped Resident 4 with pain relief. Resident 4 stated Resident 4 called 9-1-1 (emergency medical services) and Resident 4 was transported to GACH 1 at 2 pm for pain management. Resident 4 stated Resident 4 was given Morphine (unable to indicate the dose) at GACH 1 on 10/18/2023, at 4:09 pm (12 hours later). Resident 4 stated Resident felt worthless, awful, and about to die when the facility failed to address Resident 4's pain management concerns. Residents Affected - Few During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDS Nurse (MDSN), Resident 4's Order Listing Report (OLR), dated October 2023 and MAR, dated October 2023 were reviewed. The MDSN stated Resident 4's OLR indicated Resident 4 was ordered Norco 5-325 milligram (mg, unit of measurement), give one (1) tablet every four hours (q4h) as needed for moderate pain on 10/17/2023 by MD 1. The MDSN stated moderate pain was rated five (5) to seven (7) out of 10 on the pain NRS. The MDSN stated Resident 4's MAR indicated Resident 4 received Norco 5-325 mg for 10 of 10 pain on 10/18/2023 at 4:25 am. The MDSN stated 10 of 10 pain was considered severe pain and the worst pain a resident (in general) would have. The MDSN stated Resident 4's Norco 5-325 mg prescribed medication was not appropriate to treat Resident 4's severe pain. The MDSN stated Licensed Vocational Nurse (LVN) 4 did not contact MD 1 to report to MD 1 to request for a stronger pain medication to treat severe pain. During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the Director of Nursing (DON), Resident 4's Progress Notes, dated 10/18/2023 were reviewed. The DON stated Resident 4's notes did not indicate staff attempted to inform MD 1 of Resident 4's severe pain level. The DON stated Resident 4's pain level was eight (8) out of 10 on 10/18/2023 at 12:40 pm. The DON stated eight (8) of 10 was considered severe pain. The DON stated Norco was not intended to treat severe pain and was not an appropriate pain medication to treat Resident 4's pain. The DON stated being in severe pain could affect Resident 4's cognition, ability to make decisions, answer questions, and function. The DON stated Resident 4 called 9-1-1 and was transferred to GACH 1 on 10/18/2023, at 2:55 pm. During an interview on 12/8/2023 at 4:54 pm, with the DON, the DON stated Resident 4 general) was experiencing pain for 12 hours without receiving appropriate pain medication. The DON stated pain was subjective and it was staffs' responsibility to maintain Resident 4's comfort level and attempt to inform MD 1 when Resident 4 was in pain and the pain was not being managed appropriately with the medication ordered (Norco). The DON stated, being in that much pain could affect a resident's mood, cause anger, frustration, and lead to depression. During a review of the facility's policy and procedure (PP) titled, Guidelines for Notifying Physicians of Clinical Problems, dated September 2017, the PP indicated the guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient and effective manner and that all significant changes in a resident/patient status are assessed and documented in the medical record. The PP indicated immediate notification (acute) problems included the symptoms, and/or signs such as sudden onset or a marked changed (for example, much more severe or frequent) compared to usual or baseline and are unrelieved by measures which had already been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 2 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0580 prescribed or attempted. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's PP titled, Pain Assessment and Management, revised October 2022, the PP indicated the purpose was to help staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs that addressed the underlying causes of pain. The PP indicated if pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The PP indicated to report the following information to the physician or other practitioner: significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 3 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview and record review, the facility failed to provide appropriate pain management for one of six sampled residents (Resident 4) by failing to: Residents Affected - Few 1. Ensure Licensed Vocational Nurses (LVN) 3 and 4 called Medical Doctor (MD) 1 to obtain a new order when Resident 4 experienced lower back pain (pain in lower portion of the back) ranging from eight (8) to 10 out of 10 based on a numerical rating scale (NRS, requiring the resident to rate their pain on a defined scale, zero (0) to 10, 0 being no pain, one (1) to three (3) being mild pain, four (4) to six (6) being moderate pain, seven (7) to nine (9) being severe pain and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. 2. Ensure MD 1 and the Medical Director (MDD) authorized the pharmacy to deliver Norco (Hydrocodone-acetaminophen, medication used to treat moderate pain) 5-325 milligram (mg, unit of measurement) per Resident 4 ' s Order Listing Report (OLR). As a result of these failures, on 10/18/2023, Resident 4 endured 12 hours of severe lower back pain (from 10/18/2023, at 4:25 am to 10/18/2034, at 4:09 pm) before Resident 4 was transferred to General Acute Care Hospital (GACH) 1 and received Morphine (narcotic medication used to treat severe pain) for pain relief. Cross Reference: F580 and F710 Findings: 1. During a review of Resident 4 ' s admission Record (AR), the AR indicated the facility admitted Resident 4 on 10/17/2023 with diagnoses including unspecified low back pain, muscle wasting and atrophy (thinning of muscle mass caused by disuse of the muscles), and abnormalities of gait and mobility (inability to walk normally due to injuries of underlying conditions). During a review of Resident 4 ' s emergency room Physician Note from GACH 1, dated 10/18/2023 at 4:06 pm, the note indicated Resident 4 was diagnosed with acute exacerbation (flare-up of symptoms from an existing illness) of chronic (long-term) lumbar (lower) back pain. Resident 4 received acetaminophen (mild pain medication) 1000 milligram (mg- unit of measurement) by mouth on 10/18/2023, at 4:09 pm. The note indicated Resident 4 received morphine sulfate injection four (4) mg by intra-muscular injection (shot into the muscle) on 10/18/2023, at 4:10 pm. During a review of Resident 4 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/26/2023, the MDS indicated Resident 4 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 4 required partial/moderate (staff provided less than half the effort and lifts or holds trunk) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 4 was dependent (staff provided total help) with toileting hygiene and showering/bathing self. During an interview on 12/8/2023 at 10:55 am, with Resident 4, Resident 4 stated on 10/18/2023, Resident 4 ' s pain was at an eight (8, severe pain) out of 10 on the pain NRS. Resident 4 stated on 10/18/2023, at 4 am, Resident 4 received one (1) dose of Norco. Resident 4 stated when the pain returned (unknown time) Resident 4 requested for Resident 4 ' s next dose of pain medication and the nurse (unable to identify) told Resident 4 the medication was not ready. Resident 4 stated Resident 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 4 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0697 Level of Harm - Actual harm Residents Affected - Few requested pain medication all morning. Resident 4 stated Resident 4 ' s pain was unmanaged (no relief) and no one in the facility helped Resident 4 with pain relief. Resident 4 stated Resident 4 called 9-1-1 (emergency medical services) and Resident 4 was transported to GACH 1 at 2 pm for pain management. Resident 4 stated Resident 4 was given Morphine (unable to indicate the dose) at GACH 1 on 10/18/2023, at 4:09 pm (12 hours later). Resident 4 stated Resident felt worthless, awful, and about to die when the facility failed to address Resident 4 ' s pain management concerns. During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDS Nurse (MDSN), Resident 4 ' s Order Listing Report (OLR), dated October 2023 and MAR, dated October 2023 were reviewed. The MDSN stated Resident 4 ' s OLR indicated Resident 4 was ordered Norco 5-325 mg, give one (1) tablet every four hours (q4h) as needed for moderate pain on 10/17/2023 by MD 1. The MDSN stated Resident 4 ' s MAR indicated Resident 4 received Norco 5-325 mg for 10 of 10 pain on 10/18/2023 at 4:25 am. The MDSN stated 10 of 10 pain was considered severe pain and the worst pain a resident (in general) would have. The MDSN stated Resident 4 ' s Norco 5-325 mg prescribed medication was not appropriate to treat Resident 4 ' s severe pain. The MDSN stated LVN 4 did not contact MD 1 to report to MD 1 to request for a stronger pain medication to treat severe pain. During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the Director of Nursing (DON), Resident 4 ' s Progress Notes, dated 10/18/2023 were reviewed. The DON stated Resident 4 ' s notes did not indicate staff attempted to inform MD 1 of Resident 4 ' s severe pain level. The DON stated Resident 4 ' s pain level was eight (8) out of 10 on 10/18/2023, at 12:40 pm. The DON stated eight (8) out of 10 was considered severe pain. The DON stated Norco was not intended to treat severe pain and was not an appropriate medication for Resident 4. The DON stated being in severe pain could affect Resident 4 ' s cognition, ability to make decisions, answer questions, and function. The DON stated Resident 4 called 9-1-1 and was transferred to GACH 1 for pain management. During a review of Resident 4 ' s Progress Note, dated 10/18/23, timed 2:55 pm, the note indicated Resident 4 had an order to transfer Resident 4 to GACH 1 for an evaluation and management of severe pain. The note indicated transportation services were arranged for Resident 4 to be transferred to GACH 1. During a telephone interview on 12/18/2023 at 2:46 pm, with LVN 3, LVN 3 stated Resident 4 called 9-1-1 because Resident 4 was in so much pain. LVN 3 stated LVN 3 did not attempt to reach MD 1 to inform MD 1 of Resident 4 ' s severe pain. LVN 3 stated LVN 3 attempted to call MD 1 on 10/18/2023, at 10:53 am and at 12:40 pm to get the Norco 5-325 mg medication authorized for pharmacy to deliver the Norco. LVN 3 stated Resident 4 called 9-1-1 before MD 1 response to LVN 3 ' s phone calls. During an interview on 12/8/2023 at 4:54 pm, with the DON, the DON stated Resident 4 was experiencing pain for 12 hours without receiving appropriate pain medication. The DON stated pain was subjective and it was the nursing staffs ' (in general) responsibility to maintain Resident 4 ' s comfort level and attempt to inform MD 1 when Resident 4 was in pain. The DON stated Resident 4 ' s pain was not being managed appropriately with the medication ordered (Norco). The DON stated, being in that much pain could affect a resident ' s mood, cause anger, frustration, and lead to depression. 2. During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDSN, Resident 4 ' s Progress Note dated 10/18/2023 at 7:38 am was reviewed. The MDSN stated LVN 3 indicated Resident ' s 4 Norco dose on 10/18/2023 at 4:25 am was taken from the facility ' s emergency kit (e-kit- medication kit used when pharmacy has not delivered consistent doses). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 5 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0697 Level of Harm - Actual harm Residents Affected - Few During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the DON, the DON reviewed Resident 4 ' s OLR and Progress Notes, dated 10/18/2023. The DON stated on 10/17/2023, MD 1 ordered for Resident 4 to receive Norco 5-325 mg for pain management, however MD 1 had not provided an authorization for the medication to be delivered by the pharmacy. The DON stated Norco 5-325 mg was a controlled substance (high potential for abuse, with use potentially leading to severe psychological or physical dependence), and it required MD 1 to contact the pharmacist (unidentified) to authorize the delivery of narcotic medications (Norco), as a safety measure. The DON stated a medication e-kit was used when a medication was not otherwise available in instances such as a newly admitted residents (in general) and/or for newly prescribed medications. The DON stated Resident 4 was a newly admitted resident and the Norco order was pending an authorization by MD 1 for medication delivery. The DON stated only one (1) dose of Norco 5-325 mg was available in the e-kit which was administered to Resident 4. During a telephone interview on 12/8/2023 at 2:02 pm, with MD 1, MD 1 stated the protocol for signing authorization on a narcotic or controlled substance medication. MD 1 stat should not take more than 20 minutes. During a concurrent review of telephone record an interview on 12/8/2023 at 2:46 pm, with LVN 3, LVN 3 stated LVN 3 attempted to reach both MD 1 and the MDD multiple times throughout LVN 3 ' s shift on 10/18/2023 at 10: 53 am, 123:40 pm and 1:55 pm. LVN 3 stated LVN 3 was attempting to reach MD 1 to get Norco authorized for delivery for Resident 4 but she did not get a call back from MD 1 nor MDD. During a telephone interview on 12/8/2023 at 3:29 pm, with the MDD, the MDD stated part of the MDD ' s job was to be available if the primary physicians (in general) were not available. The MDD stated the MDD worked to solve problems related to medical issues at the facility. The MDD stated the MDD was on-call and available 24 hours a day, seven days a week. During a review of the facility ' s PP titled, Guidelines for Notifying Physicians of Clinical Problems, dated September 2017, the PP indicated the guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient and effective manner and that all significant changes in a resident/patient status are assessed and documented in the medical record. The PP indicated the charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management. The PP indicated the practitioner was responsible for responding in a timely manner to calls, especially regarding immediate notification problems. The PP indicated immediate notification (acute) problems included the symptoms, and/or signs such as sudden onset or a marked changed (for example, much more severe or frequent) compared to usual or baseline and are unrelieved by measures which had already been prescribed or attempted. During a review of the facility ' s PP titled, Pain Assessment and Management, revised October 2022, the PP indicated the purpose was to help staff identify pain in the resident, and to develop interventions that were consistent with the resident ' s goals and needs that addressed the underlying causes of pain. The PP indicated pain management was defined as the process of alleviating the resident ' s pain abased on his or her clinical condition and established treatment goals. The PP indicated acute pain (or significant worsening of chronic pain) should be assessed every 30 minutes to 60 minutes after the onset and reassessed as indicated until relief is obtained. The PP indicated if pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The PP indicated to report the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 6 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0697 information to the physician or other practitioner: significant changes in the level of the resident ' s pain and prolonged, unrelieved pain despite care plan interventions. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 7 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of six sampled residents (Resident 4) by failing to: Residents Affected - Some 1. Ensure Medical Doctor (MD) 1 provided treatment to authorize Norco (Hydrocodone-acetaminophen, used to treat moderate pain) 5-325 milligram (mg, unit of measurement) to be delivered by the pharmacy per Resident 4 ' s Order Listing Report (OLR) when contacted by the facility staff. 2. Ensure the Medical Director (MDD) was reachable by phone to provide treatment for Resident 4's pain when MD 1 was not reachable by phone by facility staff. As a result of these failures, Resident 4 endured 12 hours of severe pain before being transported to General Acute Care Hospital (GACH) 1 for pain relief. Cross Reference: F697 Findings: 1. During a review of Resident 4 ' s admission Record (AR), the AR indicated Resident 4 was admitted to the 10/17/2023, with diagnoses that included unspecified low back pain (pain in lower portion of back), muscle wasting and atrophy (thinning of muscle mass caused by disuse of the muscles or neurogenic conditions), and abnormalities of gait and mobility (inability to walk normally due to injuries or underlying conditions). During a review of Resident 4 ' s emergency room Physician Note from GACH 1, dated 10/18/2023 at 4:06 pm, the note indicated Resident 4 was diagnosed with acute exacerbation (flare-up of symptoms from an existing illness) of chronic (long-term) lumbar (lower) back pain. Resident 4 received acetaminophen (mild pain medication) 1000 milligram (mg- unit of measurement) by mouth on 10/18/2023, at 4:09 pm. The note indicated Resident 4 received morphine sulfate injection four (4) mg by intra-muscular injection (shot into the muscle) on 10/18/2023, at 4:10 pm. During a review of Resident 4 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/26/2023, the MDS indicated Resident 4 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 4 required partial/moderate (staff provided less than half the effort and lifts or holds trunk) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 4 was dependent (staff provided total help) with toileting hygiene and showering/bathing self. During an interview on 12/8/2023 at 10:55 am, with Resident 4, Resident 4 stated on 10/18/2023, Resident 4 ' s pain was at an eight (8, severe pain) out of 10 on the pain NRS. Resident 4 stated on 10/18/2023, at 4 am, Resident 4 received one (1) dose of Norco. Resident 4 stated when the pain returned (unknown time) Resident 4 requested for Resident 4 ' s next dose of pain medication and the nurse (unable to identify) told Resident 4 the medication was not ready. Resident 4 stated Resident 4 requested pain medication all morning. Resident 4 stated Resident 4 ' s pain was unmanaged (no relief) and no one in the facility helped Resident 4 with pain relief. Resident 4 stated Resident 4 called 9-1-1 (emergency medical services) and Resident 4 was transported to GACH 1 at 2 pm for pain management. Resident 4 stated Resident 4 was given Morphine (unable to indicate the dose) at GACH 1 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 8 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/18/2023, at 4:09 pm (12 hours later). Resident 4 stated Resident felt worthless, awful, and about to die when the facility failed to address Resident 4 ' s pain management concerns. During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the DON, the DON reviewed Resident 4 ' s OLR and Progress Notes, dated 10/18/2023. The DON stated on 10/17/2023, MD 1 ordered Resident 4 Norco 5-325 mg, however MD 1 had not provided authorization for the medication to be delivered by the pharmacy. The DON stated Norco 5-325 mg was a controlled substance (high potential for abuse, with use potentially leading to severe psychological or physical dependence), requiring physicians (in general) to be contacted by the pharmacist (in general) to authorize the delivery of narcotic medications, as a safety measure. The DON stated Resident 4 was a newly admitted resident and pending authorization by Resident 4 ' s MD 1 for medication delivery. The DON stated Resident 4 ' s Progress Notes indicated the following on 10/18/2023: a. At 9:16 am, LVN 5 placed a call to MD 1 ' s office regarding Norco 5-325 mg authorization to process. b. At 10:53 am, LVN 3 called MD 1 who was unable to reached. Message was sent to MDD. c. At 12:40 pm, LVN 3 called MD 1 who was unable to be reached. Called MDD who was unable to be reached. d. At 1:55 pm, LVN 3 indicated Quality Assurance Nurse (QAN) sent a message and attempted to follow up with MD 1 multiple times. During a telephone interview on 12/18/2023 at 2:46 pm, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 4 called 9-1-1 because Resident 4 was in so much pain. LVN 3 stated LVN 3 did not attempt to reach MD 1 to inform MD 1 of Resident 4 ' s severe pain. LVN 3 stated LVN 3 only attempted to call MD 1 to get the Norco 5-325 mg medication authorized for pharmacy to deliver the medication. During a telephone interview on 12/8/2023 at 2:02 pm, with MD 1, MD 1 stated the protocol for signing authorization on a narcotic or controlled substance medication was that the facility staff needed to call MD 1 so MD 1 could authorize the pharmacy to deliver the medication. MD 1 stated the process should not take more than 20 minutes. MD 1 stated MD 1 did not recall receiving any phone calls on 10/18/2023 regarding Resident 4 ' s severe pain or needing Norco authorized for delivery. During a telephone interview on 12/8/2023 at 2:46 pm, with LVN 3, LVN 3 stated LVN 3 attempted to reach both MD 1 and the MDD multiple times throughout LVN 3 ' s shift on 10/18/2023. LVN 3 stated LVN 3 was attempting to reach MD 1 to get Norco authorized for delivery for Resident 4. During an interview on 12/8/2023 at 3:15 pm, with the QAN, the QAN stated LVN 3 asked for assistance after having trouble reaching MD 1 and the MDD. The QAN stated the QAN attempted to reach MD 1 and left a message sometime between 12 pm and 2 pm on 10/18/2023. The QAN stated sometimes MD 1 was reachable and sometimes MD 1 was not. During an interview on 12/8/2023 at 4:54 pm, with the DON, the DON stated residents (in general) should not go 12 hours without receiving appropriate pain medication. The DON stated pain was subjective and it was staffs ' responsibility to maintain the residents ' comfort level and attempt to inform the physicians (in general) when residents (in general) are in pain and are not being managed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 9 of 10 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 055372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Post Acute 3111 Santa Anita Ave El Monte, CA 91733 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)

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some appropriately with the medication ordered. The DON stated, being in that much pain could affect a resident ' s mood, cause anger, frustration, and lead to depression. The DON stated being in severe pain for over 12 hours had the potential to cause physical decline and lead to hospitalization. 2. During a telephone interview on 12/8/2023 at 3:29 pm, with the MDD, the MDD stated part of the MDD ' s job was to be available if the primary physicians (in general) were not available. The MDD stated the MDD was on-call and available 24 hours a day, seven days a week. The MDD stated the MDD had approximately 200 patients. The MDD stated the MDD had no knowledge of Resident 4. The MDD stated the MDD did not recall receiving any calls regarding Resident 4 on 10/18/2023. The MDD stated the protocol for getting narcotics authorized for pharmacy delivery was to have the primary physician, like MD 1 authorize the medication. The MDD stated if the primary physician (in general) was not reachable, staff were supposed to call the MDD for assistance. During a concurrent observation and interview on 12/8/2023 at 4:02 pm, with LVN 6, LVN 6 reviewed MD 1 and the MDD ' s telephone contact information in the facility issued cellphone. LVN 6 stated MD 1 and the MDD ' s contact information were correct. During a review of the facility ' s PP titled, Physician Services, revised 2/2021, the PP indicated the medical care of each resident was supervised by a licensed physician. The PP indicated once a resident was admitted , orders for the resident ' s immediate care and needs could be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The PP indicated supervising the medical care needs of residents included but was not limited to monitoring changes in resident ' s medical status, providing consultation or treatment when called by the facility, prescribing medications and therapy, and overseeing a relevant plan of care for the resident. During a review of the facility ' s PP titled, Guidelines for Notifying Physicians of Clinical Problems, 9/2017, the PP indicated the guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in a resident/patient status are assessed and documented in the medical record. The PP indicated the charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management. The PP indicated the practitioner was responsible for responding in a timely manner to calls, especially regarding immediate notification problems. The PP indicated immediate notification (acute) problems included the symptoms, and/or signs such as sudden in onset or a marked changed (for example, much more severe or frequent) compared to usual or baseline and are unrelieved by measures which had already been prescribed or attempted. During a review of the facility ' s PP titled, Pain Assessment and Management, revised October 2022, the PP indicated if pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The PP indicated to report the following information to the physician or other practitioner: significant changes in the level of the resident ' s pain and prolonged, unrelieved pain despite care plan interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 10 of 10