Health inspection·April 11, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided with a comfortable environment by failing to: Maintain hot water temperature of the water faucet in the restroom sink of Resident 1's room (Room A) in accordance with the facility's policies and procedures (P&P) titled, Residential Care Facilities for the Elderly and Accommodation of Needs. This deficient practice resulted in Resident 1 not having hot water to use in the restroom and had the potential for Resident 1 to feel uncomfortable during routine personal care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with multiple diagnoses including traumatic hemorrhage of cerebrum (bleeding in the largest part of the brain), multiple fractures (a complete or partial break in a bone) of bilateral ribs, and pneumothorax (a collapsed lung). During a review of Resident 1's History and Physical Examination (H&P), dated 1/2/24, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, an assessment and screening tool), dated 1/2/24, the MDS indicated, Resident 1's cognitive (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 1 required partial/moderate assistance (helper did less than half the effort) with personal hygiene including washing/drying face and hands. During a concurrent interview and record review on 4/11/24 at 11:24 a.m. with the Maintenance Supervisor (MS), the facility's Maintenance Log (ML), dated 3/2024, was reviewed. The ML indicated, on 3/12/24, Room A had no hot water in faucet. The MS stated his duties included maintaining the building and ensuring everything is working properly, including water temperature and finding the solution and fixing whatever was needed. The MS stated Room A's no hot water issue was an easy fix where MS only had to open the hot water valve underneath the sink that someone had closed. During a concurrent observation and interview on 4/11/24 at 11:46 a.m. with the MS, Room A's water faucet temperature in the restroom was checked for five (5) minutes. The temperature fluctuated between 100.5 degrees F (Fahrenheit, the standard scale used to measure temperature in the United States) and 101 degrees F. The MS stated the water felt lukewarm and not hot. The MS stated the hot water (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 04/11/2024 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)