Health inspection·June 14, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse for two of four sampled residents (Residents 3 and 4) to the State Licensing and Certification Agency (responsible for the licensing or certification of health care facilities), the Ombudsman and to the local law enforcement within two hours, in accordance with the facility's Policy and Procedure (P&P) on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice had the potential for delayed investigation that would compromise Residents 3 and 4's safety with potential for further abuse. Findings: During a review of Resident 3's admission Records (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included acute heart failure (sudden condition when the heart can't pump enough oxygen to the body) and Diabetes Mellitus (a disease that result in too much sugar in the blood). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/13/2024, the MDS indicated Resident 3 had intact cognition (ability to understand) and required moderate assistance (helper does less than half the effort) with toileting, shower, and lower body dressing. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental condition that causes both a loss of contact with reality [psychosis] and mood problems) and anxiety (an unpleasant state of inner turmoil and fear). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had moderately impaired cognition, and required maximal assistance (helper does more than half the effort) with oral and toileting hygiene, upper body dressing and personal hygiene. During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341), dated 6/10/2024, the SOC 341 indicated Resident 4 allegedly came in contact with Resident 3's left arm in the dining hall. The alleged resident to resident incident happened on 6/10/24 at 7:45 am. During a review of Fax Confirmations (FC) dated 6/10/2024, the FC indicated, the SOC 341 was faxed to the State Licensing and Certification Agency on 6/10/2024 at 12:07 pm. (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 3 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 06/14/2024 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)