Health inspection·December 13, 2023

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents ' room (Resident 1 ' s room) met the requirement of 80 square feet (sq. ft.) per resident in room [ROOM NUMBER]. room [ROOM NUMBER] was previously denied by Center for Medicare and Medicaid Services (CMS). The facility failed to comply after the request for the room waiver was denied by the CMS. This deficient practice had the potential to result in inadequate nursing care to the resident. Findings: A review of the CMS letter, dated 1/24/2018, indicated CMS denied the request for a waiver/variation of the room size requirement for Resident 1's room. The letter indicated the minimum square footage for a 4-bedroom was 320 sq. ft. This room was below the minimum requirement by 32 sq. ft. for a 4-bedroom room and could lead to possible inadequate spacing for nursing care needs to the residents in Resident 1's room. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The AR indicated Resident 1 had diagnoses including abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly cause walking disturbances) and muscle wasting and atrophy (wasting or thinning of your muscle mass). During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/30/2023, the MDS indicated Resident 1 was cognitively intact (ability to make daily decisions). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports truck of limbs, but provides less than half the effort) for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 12/13/2023 at 12:17 pm, in Resident 1's room, Resident 1's room had four (4) beds present, occupied by four (4) residents. Resident 1's wheelchair was tucked away in between Resident 1's bed and the wall with a sink, blocked by Resident 1's bedside table. Resident 1 stated Resident 1 could not put Resident 1's wheelchair on the other side of Resident 1's bed because there was another resident there and there was not enough space between Resident 1's bed, the curtain, and the roommate. During a concurrent interview and record review on 12/13/2023 at 2:59 pm, with the Administrator (ADM), the room waiver request from 2017 was reviewed. The ADM stated the facility did not have an (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: 055372 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 12/13/2023 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)