Inspection·April 9, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the interventions provided to Resident 1 when she had a low blood sugar level of 37 (hypoglycemia), was documented in the medical record. This failure had the potential to affect Resident' 1's health and make it harder for nursing staff to communicate effectively and provide proper care. Findings: A review of Resident 1's admission record indicated she was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar level). A review of Resident 1's History and Physical dated December 19, 2024, indicated she had the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) for the month of January 2025 indicated she had a blood sugar level of 37 at 6:30 a.m. on January 1, 2025. A review of Resident 1's SBAR (Situation Background Assessment Recommendation- a standardized communication tool) Communication Form and progress note . written by Licensed Vocationa Nurse (LVN) 1, indicated Resident 1 had hypoglycemia on January 1, 2025, at 6:15 a.m. and the physician was notified. There was no other documented evidence that interventions were provided to manage Resident 1's hypoglycemia on January 1, 2025. In addition there was no documented evidence Resident 1 physician responded to the notification. On March 24, 2025, at 1:48 p.m. during a concurrent interview with LVN 1 and record review of Resident 1's medical record, LVN 1 stated she was notified that Resident 1 had a low blood sugar level, she notified the physician and initiated an SBAR. LVN 1 stated there were no new orders from Resident 1's physician. LVN 1 stated for residents with a blood sugar level of 70 and below, the orange juice or glucagon is provided to the resident and the physician would be notified. LVN 1 stated there was no documentation in Resident 1's medical record that interventions were provided to manage Resident 1's low blood sugar level. LVN 1 stated when orange juice or glucagon was given, it should be documented in Resident 1's medical record. On March 24, 2025, at 2:54 p.m., during a telephone interview with LVN 2, she stated she was (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 04/09/2025 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)