Health inspection·January 5, 2024

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's Order Summary Report (OSR) dated 1/4/2024, the OSR indicated a physician order dated 12/1/2023, for the facility to discharge Resident 2 on 12/4/2023 to Address 1 with home health and DME: FWW. During a review of Resident 2's OSR dated 1/4/2024, the OSR indicated a physician order dated 12/21/2023, for the facility to discharge Resident 2 on 12/21/2023 to Address 1 with home health and DME: FWW. During a telephone interview on 1/4/2024 at 2:13 pm with Responsible Party 2 (RP 2), RP 2 stated on 12/21/23, RP 2 picked up Resident 2 from the facility and took Resident 2 to a motel (unable to name). RP 2 stated, Resident 2 had been homeless for over five years. During a concurrent interview and record review on 1/4/2024 at 4:55 pm with the QAN, Resident 2's medical record was reviewed. The QAN stated, the physician order dated 12/1/2023, for the proposed discharge on [DATE], was canceled so the facility could better prepare and have a safer discharge plan for Resident 2. The QAN stated, QAN was not sure if HHA or DME referrals were arranged for the proposed discharge on [DATE] before the discharge order was canceled. The QAN stated, on 12/21/2023, Resident 2 requested to be discharged . The QAN stated, Resident 2 provided Address 1 to QAN as Resident 2's discharge location. The QAN stated, QAN did not confirm Address 1 was Resident 2's home and did not check if Address 1 was an appropriate discharge location for Resident 2. The QAN stated, it was the SSD's responsibility to ensure Address 1 was a safe and appropriate discharge location for Resident 2. The QAN stated, Resident 2 was homeless prior to Resident 2's admission to the facility. The QAN stated, the QAN thought Resident 2 was going to stay with RP 2. The QAN stated, the QAN was supposed to ensure referrals for HHA and DME were arranged before discharge so Resident 2 could be safely discharged . The QAN stated, Resident 2 was at risk for unsafe discharge because the referrals for HHA and DME were not completed, therefore Resident 2 could not get the services and equipment to successfully transition into the community. During an interview on 1/4/2024 at 5:48 pm with the Director of Nursing (DON), the DON stated the SSD was supposed to ensure all residents being discharged had a safe place to go. During an interview on 1/4/2024 at 6:04 pm with the SSD, the SSD stated on 12/21/2023, Resident 2 requested to be discharged from the facility. The SSD stated, Resident 2 provided Address 1 as Resident 2's discharge location. The SSD stated, SSD did not ensure Address 1 would meet Resident 2's health and safety needs and was an appropriate discharge location for Resident 2. The SSD stated, (in general) referrals for HHA and DME needed to be in place before discharge to ensure a smooth and safe transition to the community. During a telephone interview on 1/4/2024 at 6:33 pm with MD 1, MD 1 stated Resident 2 needed a referral for HHA for the care of Resident 2's colostomy (an operation that creates an opening for the colon or large intestine, through the abdomen that allows for bowel movement to pass through) and to address Resident 2's care and services needs after discharge into the community. MD 1 stated, Resident 2 needed referral for DME in the form of a FWW because of Resident 2's history of unsteady gait. MD 1 stated, (in general) the facility was supposed to set these services up when discharging MD 1's residents. During an interview on 1/5/2024 at 11:00 am with the SSD, the SSD stated the SSD did not get a referral for HHA or DME for Resident 2 because the SSD thought another staff already did it. The SSD stated, referrals for HHA and DME were needed for Resident 2 to be safely discharged . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 2 of 6 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 01/05/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 1/5/2024 at 1:52 pm with the DON, the DON stated Resident 2 was discharged from the facility without HHA and DME referrals/authorization. The DON stated, (in general) HHA and DME referrals needed to be made before discharging a resident, if ordered by a physician, to ensure a safe discharge. The DON stated, this was a safeguard used to ensure residents were discharged safely and received the care and services needed after leaving the facility. The DON stated, not getting a referral/authorization for HHA or DME made the discharge of a resident unsafe. The DON stated, without those services, a resident's physical and mental health could decline and lead to rehospitalization. Event ID: Facility ID: 055372 If continuation sheet Page 3 of 6 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 01/05/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a post-discharge (after discharge) plan of care in accordance with the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, for one of two sampled residents (Resident 2). This deficient practice had the potential for Resident 2 not to receive the necessary information for provision of care after discharge to ensure a safe transition to Resident 2's new living environment. Cross Reference F624 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/23/2023, with diagnoses of homelessness, anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and abnormalities of gait and mobility (weakness of the hip and lower extremities muscles causing unsteady balance and walking issues from an injury or underlying medical condition). During a review of Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 10/30/2023, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and reason), required partial/moderate assistance (helper does less than half the effort and lifts or holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated, Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity while assistance may be provided throughout the activity or intermittently) with rolling left and right, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. During a review of Resident 2's Order Summary Report (OSR) dated 1/4/2024, the OSR indicated a physician order dated 12/1/2023, for the facility to discharge Resident 2 on 12/4/2023 to Address 1 with home health and DME: FWW. During a review of Resident 2's OSR dated 1/4/2024, the OSR indicated a physician order dated 12/21/2023, for the facility to discharge Resident 2 on 12/21/2023 to Address 1 with home health and DME: FWW. During a telephone interview on 1/4/2024 at 2:13 pm with Responsible Party 2 (RP 2), RP 2 stated on 12/21/23, RP 2 picked up Resident 2 from the facility and took Resident 2 to a motel (unable to name). RP 2 stated, Resident 2 had been homeless for over five years. During a concurrent interview and record review on 1/4/2024 at 4:55 pm with the QAN, Resident 2's medical record was reviewed. The QAN stated, the physician order dated 12/1/2023, for the proposed discharge on [DATE], was canceled so the facility could better prepare and have a safer discharge plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 4 of 6 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 01/05/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Resident 2. The QAN stated, QAN was not sure if HHA or DME referrals were arranged for the proposed discharge on [DATE] before the discharge order was canceled. The QAN stated, on 12/21/2023, Resident 2 requested to be discharged . The QAN stated, Resident 2 provided Address 1 to QAN as Resident 2's discharge location. The QAN stated, QAN did not confirm Address 1 was Resident 2's home and did not check if Address 1 was an appropriate discharge location for Resident 2. The QAN stated, it was the Social Services Director's (SSD) responsibility to ensure Address 1 was a safe and appropriate discharge location for Resident 2. The QAN stated, Resident 2 was homeless prior to Resident 2's admission to the facility. The QAN stated, the QAN thought Resident 2 was going to stay with RP 2. The QAN stated, the QAN was supposed to ensure referrals for HHA and DME were arranged before discharge so Resident 2 could be safely discharged . The QAN stated, Resident 2 was at risk for unsafe discharge because the referrals for HHA and DME were not completed, therefore Resident 2 could not get the services and equipment to successfully transition into the community. During a concurrent interview and record review on 1/4/2024 at 5:48 pm with the DON, the facility's PP titled, Discharge Summary and Plan, was reviewed. The DON stated, the facility did not develop a post-discharge plan of care for Resident 2. The DON stated, according to the PP, the care planning/ interdisciplinary team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) did not create a post-discharge plan of care that included a safe location for Resident 2 to reside after discharge. The DON stated, the facility did not ensure RP 2, who was listed as Resident 2's caregiver, was available and capable to provide care to Resident 2. The DON stated, the facility did not follow through in the transition to post-discharge care because the referral/authorization for HHA or DME was not done. The DON stated, the facility did not evaluate what factors may cause Resident 2 to be vulnerable to preventable readmission and how those factors would be addressed. The DON stated, not doing a post-discharge plan of care placed Resident 2 at risk for being unnecessarily readmitted to the facility. The DON stated, the facility needed to create a post-discharge plan of care for every resident being discharged to ensure residents were being discharged safely. The DON stated, Resident 2's discharge was unsafe because those factors were not addressed before Resident 2 was discharged on 12/21/2023. The DON stated, Resident 2 was homeless as indicated in Resident 2's AR. During an interview on 1/4/2024 at 6:04 pm with the SSD, the SSD stated on 12/21/2023, Resident 2 requested to be discharged from the facility. The SSD stated, Resident 2 provided Address 1 as Resident 2's discharge location. The SSD stated, SSD did not ensure Address 1 would meet Resident 2's health and safety needs and was an appropriate discharge location for Resident 2. The SSD stated, (in general) referrals for HHA and DME needed to be in place before discharge to ensure a smooth and safe transition to the community. During an interview on 1/5/2024 at 11:00 am with the SSD, the SSD stated Resident 2 originally requested to be discharged from the facility on 12/1/2023 and was planned to be discharged on 12/4/2023. The SSD stated, the three days in between the requested day of discharge and proposed day of discharge were for planning for Resident 2's discharge needs. The SSD stated, Resident 2 was not discharged on 12/4/2023 because the facility convinced Resident 2 to stay so the facility could have more time to plan Resident 2's discharge and find alternative placement for Resident 2. The SSD stated, the post-discharge plan of care was not made for Resident 2 for the proposed discharge date of 12/4/2023. The SSD stated, SSD did not get a referral for HHA or DME for Resident 2 because the SSD thought another staff already did it. The SSD stated, referrals for HHA and DME were needed for Resident 2 to be safely discharged . During a review of the facility's PP titled, Discharge Summary and Plan, revised in 10/2022, the PP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055372 If continuation sheet Page 5 of 6 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 01/05/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated when a resident's discharge was anticipated, a DCS and post-discharge plan was developed to assist the resident with discharge. The PP indicated every resident was evaluated for his or her discharge needs and had individualized post-discharge plan. The PP indicated the post-discharge plan was developed by the care planning/IDT with the assistance of the resident and his or her family members and included: where the individual planned to reside; arrangements that have been made for follow-up care and services; a description of the resident's stated discharge goals; the degree of caregiver/support person availability, capacity and capability to perform required care; how the IDT will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed. The PP indicated a member of the IDT reviewed the final post-discharge plan with the resident and family at least 24 hours before the discharge was to take place. The PP indicated a copy of the following was provided to the resident and receiving facility and a copy will be filed in the resident's medical records: An evaluation of the resident's discharge needs; the post-discharge plan; and the discharge summary. Event ID: Facility ID: 055372 If continuation sheet Page 6 of 6