Health inspection·May 28, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) the same time the notice of the discharge was provided to the resident or resident ' s representative for two of six sampled residents (Residents 1 and 3). This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was discharged to home on May 15, 2025. A review of Resident 1 ' s discharge notice indicated the resident was provided the discharge notice on May 7, 2025, with the discharge effective date of May 15, 2025. A review of the fax (facsimile) transmission document sent to the Office of the State LTC Ombudsman indicated the discharge notice for Resident 1 was sent to the Ombudsman on May 12, 2025 (5 days after the notice was given to the resident). A review of Resident 3 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included acute osteomyelitis right ankle foot (bone infection of the right ankle foot) and traumatic amputation of right great toe (surgical removal of the great toe). Further review of the record indicated the resident was discharged to an assisted living on May 26, 2025. Areview of Resident 3 ' sNotice of Transfer/Discharge, indicated the resident and the resident ' s representative were provided the discharge notice on May 23, 2025. The notice indicated the effective date of the discharge is on May 26, 2025. A review of the fax transmission document sent to the office of the State LTC Ombudsman indicated the discharge notice for Resident 3 was sent to the Ombudsman on May 26, 2025 (3 days after the resident or resident ' s representative was given the discharge notice). On May 28, 2025, at 3:30 p.m., during a concurrent interview and record review with the Social (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 05/28/2025 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)