Villa Valencia Healthcare Center

F 0558

findings.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Valencia Healthcare Center

25000 Calle DE Los Caballeros Laguna Hills, CA 92653

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 0656 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed to reflect the individual care needs for one of four sampled residents (Resident 3) reviewed for care plans. * The facility failed to ensure a care plan was developed for

the use of the anticoagulant medication ordered by the physician. This failure had the potential for the resident to not be provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Plans revised 12/2016 showed the following:- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; and - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Medical record review for Resident 3 was initiated on 10/10/25. Resident 3 was admitted to the facility on [DATE REDACTED]. Review of Resident 3's Order Summary Report dated 10/6/25, showed a physician's order dated 10/5/25, for apixaban (medication to prevent blood clots) oral tablet 2.5 mg, to give one tablet by mouth one time a day for Atrial Fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly). Review of Resident 3's H&P examination dated 10/7/25, showed the resident had the capacity to understand and make decisions. Further review Resident 3's medical record failed to show a care plan was developed to address the use of the anticoagulant medication. On 10/10/25 at 1007 hours, an interview and concurrent health record review for Resident 3 was conducted with RN 1.

RN 1 verified there was a physician's order for the apixaban medication. RN 1 also verified there was no care plan developed for the use of the anticoagulant medication for Resident 3. RN 1 stated she was not responsible for developing care plans for the use of the anticoagulant medication upon admission. In addition, RN 1 stated the DON, ADON, and MRD were responsible for auditing new admissions for completion. On 10/10/25 at 1212 hours, an interview was conducted with LVN 2. LVN 2 was asked about

the importance of initiating a care plan for a resident receiving an anticoagulant. LVN 2 stated the anticoagulant medications must have a care plan to show goals and interventions such as monitoring for side effects and re-assess outcomes. On 10/10/25 at 1251 hours, an interview was conducted with the MRD. The MRD stated she would review and audit new admission charts for the completion of medication entries, baseline assessments, and care plans; however, the ADON and MDS Coordinator would be responsible in reviewing and initiating the care plan for medications. On 10/10/25 at 1403 hours, an

interview was conducted with the MDS Coordinator. The MDS Coordinator was asked when the care plan for anticoagulant use must be initiated for Resident 3. The MDS Coordinator stated the care plan for the use of anticoagulant must be initiated as soon as possible. The MDS Coordinator verified Resident 3's medical

record failed to show a care plan for the use of anticoagulant was developed. On 10/10/25 at 1536 hours,

an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Valencia Healthcare Center

25000 Calle DE Los Caballeros Laguna Hills, CA 92653

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

developed when Resident 1 had poor meal intake. Furthermore, RN 1 stated the negative outcome would cause Resident 1's condition to decline because he was not consuming the appropriate nutrients. On 10/10/25 at 1100 hours, an interview and concurrent medical record review were conducted with CNA 1.

CNA 1 verified Resident 1's poor meal intakes dated 9/13 to 9/17/25. CNA 1 stated Resident 1 became weaker, refused to participate with activities, and refused to get up in wheelchair after four to five days of admission. CNA 1 stated she reported Resident 1's change of condition including the significant decrease

in meal intake to the charge nurses. On 10/10/25 at 1212 hours, a telephone interview was conducted with LVN 2. LVN 2 was asked what she would consider a change of condition, and stated fever, abnormal labs, decline in activities of daily living (ADL), new pain or increase pain, ALOC (altered level of consciousness), abnormal vital signs blood pressure below100/60 mmHg or pulse rate below 60 bpm or above 90 bpm, and refusal of meals or below 25% meal consumption. LVN 2 stated the assigned licensed nurse must assess

the resident, complete the change of condition evaluation, notify the physician, notify responsible party or family, initiate a care plan, add to the alert charting, and document the monitoring every shift for 72 hours.

Furthermore, LVN 2 stated the negative outcome would be not being able to provide the appropriate quality care and monitoring for the resident's change of condition and resident's condition could become worse. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated abnormal vital signs were not a significant change and not considered a COC (Change of Condition). The DON stated she did not expect her licensed nurses to do a follow up entry when there are abnormal vital signs and after providing interventions to reflect resident's current condition. The DON was asked how she would know when the resident's abnormal vital signs (pulse rate) improve if there were no follow up assessments and documentation of the outcome, the DON stated the nurses cannot document every hour since they had a lot of residents. The DON stated she considered a significant COC if the resident's meal intake was 0 - 25% consecutively with refusal for three to four days. The DON was informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Valencia Healthcare Center

25000 Calle DE Los Caballeros Laguna Hills, CA 92653

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

addition, the IP nurse stated she was responsible for placing the EBP signage and PPE carts with the help of her assistant. Furthermore, the IP nurse stated the negative outcome of the staff not following EBP would be spreading the staff's germs to the residents. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated it was important for all the staff to follow the EBP to prevent direct caregiver transmission of any infection to the residents. The DON was informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Valencia Healthcare Center

25000 Calle DE Los Caballeros Laguna Hills, CA 92653

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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

15, indicating cognitively intact. On 10/10/25 at 1455 hours, an observation and concurrent interview was conducted with the DON. Resident A's bed had elevated bilateral grab rails. The DON verified the findings and stated Resident A would use the bilateral grab rails for bed mobility and during physical or occupational therapy treatments. On 10/10/25 at 1503 hours, an interview and concurrent facility document review was conducted with the Maintenance Supervisor. - Review of Resident 2's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed Zones 1 through 7 were marked pass. Further review of Resident 2's Bed Rail 7 Zones Entrapment Assessment showed must assess the entrapment for Zones 1, 3, 6, and 7.

However, Zones 2, 4, and 5 should have been marked as not applicable (N/A). - Review of Resident A's Bed Rail 7 Zones Entrapment assessment dated [DATE REDACTED], showed Zones 1 through 7 were marked pass.

Further review of Resident A's Bed Rail 7 Zones Entrapment Assessment showed must assess the entrapment for Zones 1, 2, 3, 6, and 7. However, Zones 4 and 5 should have been marked as not applicable (N/A). The Maintenance Supervisor stated he was responsible for completing the entrapment assessments of the grab rails after receiving the physician's order to apply the grab rails from the ADON.

The Maintenance Supervisor stated he used the tape measure to measure the zones and referred to the FDA Bed System guide for entrapment. The Maintenance Supervisor was asked to explain how to measure Zone 5 using the facility's guide of Bed Rail 7 Zones Entrapment Assessment guide with photo of the zones. The Maintenance Supervisor stated for Zone 5, he measured from the top of the rail to the top of the mattress. The Maintenance Supervisor was informed the correct and accurate process to measure Zone 5 was to measure the length of between split bed rails, which both Residents 2 and A have bilateral upper grab rails only. The Maintenance Supervisor verified the above findings and stated the entrapment assessments were inaccurate. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON was informed of Resident 2 and A's entrapment assessments, which all the zones were marked pass.

The DON stated at least the facility did more than it was supposed to assess. The DON verified the Maintenance Supervisor's assessments were inaccurate and verified the findings.

Event ID:

Facility ID:

If continuation sheet