Inspection·October 19, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure COVID-19 (an infectious disease caused by SARS-CoV-2 Virus) outbreak was reported when a resident with symptom had tested positive for COVID-19 infection on September 4, 2023. Residents Affected - Few The facility failure had delayed early intervention to monitor and prevent virus spread and proliferation as reporting was intended to facilitate timely intervention. Findings: On September 28, 2023, at 10:10 a.m., an unannounced visit was conducted to investigate a COVID-19 outbreak. During the visit, the receptionist (Receptionist/Payroll) was observed wearing an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of 95% airborne particles) and had not been conducting active screening. The receptionist stated they have four (4) COVID-19 positive residents in the facility. On September 28, 2023, at 10:20 a.m., the Director of Nursing (DON) was interviewed. DON provided documented evidence they had notified the county but failed to report the outbreak to the state department. On September 28, 2023, the Resident and Staff COVID LINE LISTING REPORT was reviewed. The document indicated a resident and staff had developed symptoms and tested positive for COVID-19 infection on September 4 and 6, 2023, respectively. On September 28, 2023, at 10:48 a.m., a concurrent record review of SURVEILLANCE FOR INFECTIONS/INFECTIOUS DISEASES policy and interview was conducted with the Infection Preventionist Nurse (IPN). IPN stated they had reported the outbreak to the county but not from state department. IPN stated he was under the impression that when he reported to the county, they had already done so with the state. IPN stated he will make sure he will notify the state next time so they can advocate for the residents. On September 28, 2023, at 2:36 p.m., a concurrent review of the facility policy and interview with the Administrator (ADM), Assistant Administrator (AADM), DON, and IPN was conducted. It had been determined that the facility had not reported the COVID-19 Outbreak as specified in their policy. A review of the undated facility policy titled, SURVEILLANCE FOR INFECTIONS/INFECTIOUS DISEASES , indicated, To provide guideline and format for daily surveillance for reportable or cluster (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: 555331 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 555331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valencia Gardens Health Care Center 4301 Caroline Court Riverside, CA 92506 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)