Inspection·July 7, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 11's CNA (Certified Nursing Assistant) Task Chair/Bed-to-Chair Transfer dated June 8, 2025 to July 2, 2025, indicated the following: - Resident refused on the following days (none). - Not attempted and resident did not perform on the following days (6/13, 6/20, 6/21, 6/22, 6/27, and 7/2/2025). A review of Resident 11's CNA Task Showers dated June 8, 2025 to July 2, 2025, indicated the following: - Resident refused on the following days (6/3, 6/6, and 6/21/2025). - Not attempted and resident did not perform on the following days (6/13, 6/20, 6/22, and 7/2/2025). On July 2, 2025, at 12:00 p.m., a concurrent interview and record review was conducted with CNA 1. CNA 1 stated Resident 11 did not like to participate in group activities. CNA 1 stated Resident 11 refused to transfer into the wheelchair using a hoyer lift. CNA 1 stated there is no documented evidence of Resident 11's refusing to get into the wheelchair. CNA 1 stated Resident 11 should have been offered access to his wheelchair. CNA 1 stated Resident 11 refused to take showers and preferred bed baths because the Hoyer lift shower net irritated his skin. CNA 1 stated Resident 11 was not offered a shower chair on shower days. CNA 1 stated Resident 11 should have been offered a shower chair as an alternative for showers. On July 2, 2025, at 12:36 p.m., a concurrent interview and record review was conducted with the Physical Therapy Director (PTD). The PTD stated Resident 11 had two prostheses for his left BKA and can wear a shoe on his right stump. The PTD stated Resident 11's physical therapy for ambulating with his prosthesis was on hold from January 2025 to April 2025, due to wounds on both stumps. The PTD stated Resident 11 was offered to resume ambulatory physical therapy with his prosthesis on April 8, 2025, but declined. The PTD stated Resident 11 could transfer from his bed to the wheelchair with minimum to supervisory assistance. The PTD stated Resident 11 did not require a physical therapy (PT) clearance to get into his wheelchair. The PTD stated Resident 11 can use a shower chair for showers because he had good upper body strength. The PTD further stated nursing should have offered Resident 11 access to his wheelchair and the shower chair as an alternative for showers. On July 2, 2025, at 1:04 p.m., a concurrent interview and record review was conducted with the PTD, Licensed Vocational Nurse (LVN) 1, and CNA 1. The PTD informed LVN 1 and CNA 1 that Resident 11 did not require a PT clearance for access to his wheelchair. LVN 1 stated to the PTD Resident 11 had a history of refusing so nursing stopped offering Resident 11 his wheelchair. LVN 1 stated there was no documented evidence of Resident 11 refusing his wheelchair. The PTD informed LVN 1 and CNA 1 Resident 11 had good upper body strength and could have access to his wheelchair for autonomy and could use the shower chair on showers days. LVN 1 stated Resident 11 should have been offered daily access to his wheelchair and a shower chair on his shower days. On July 3, 2025, at 11:29 a.m., a concurrent interview and record review was conducted with the DON (Director of Nursing). The DON stated Resident 11 had a history of refusing care. The DON stated there was no documented evidence Resident 11 refused to use his wheelchair. The DON stated the facility process was to offer residents their wheelchairs daily and shower alternatives, especially when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 2 of 11 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 07/07/2025 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the resident has a history of pressure ulcers. The DON further stated Resident 11 should have been offered daily access to his wheelchair and shower accommodations. A review of the facility policy and procedure titled, Accommodation of Needs, revised March 2024, indicated .staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes . Event ID: Facility ID: 555331 If continuation sheet Page 3 of 11 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 07/07/2025 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration of medication for Orajel (a topical treatment for the mouth and gums to relieve pain) was completed, and had a physician order, for one of 55 residents reviewed (Resident 7). In addition, the facility failed to ensure the medication was stored properly and securely. Residents Affected - Few This failed practice increased the potential for unsafe self-administration of medication for Resident 7, and the potential for visitors, and other residents to have access to the medication, which was stored at the bedside of Resident 7. Findings: During a concurrent observation and interview on July 1, 2025, at 12:40 p.m., with Resident 7 in her room, Resident 7 was awake, alert, and able to verbalize her needs. Resident 7 was observed sitting in bed eating her lunch. Her meal ticket indicated Fortified Diet (food with added vitamins, minerals, or other nutrients) mechanical soft texture, thin liquid consistency. Resident 7 was observed without any teeth. She stated she had no dentures for years. She stated she used to have dentures but they hurt her gums. A tube of Orajel medication was observed on top of the overbed table. She stated she had been using the Orajel before each meal. She stated her gums hurt if she did not use the Orajel. She stated someone here gave me the medication. The Orajel tube was labeled with Resident 7's name, date of birth , date of admit, and physician's name. On July 1, 2025, at 3:50 p.m., the tube of Orajel was still observed on the top of Resident 7's overbed table. On July 1, 2025, at 3:58 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. She stated she did not notice the tube of Orajel at Resident 7's bedside, and she was not sure if there was a physician's order. A concurrent review of Resident 7's physician's orders for the months of June and July 2025, indicated there was no physician's order for the medication Orajel. LVN 2 stated Resident 7 should have an assessment and evaluation for self - administration of the medication if Resident 7 was administering the medication. She stated there should be a physician's order for the Orajel medication. A review of Resident 7's medical record indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (bladder infection), multi-drug resistant organism infection (MDRO - a germ that is resistant to many antibiotics), and pneumonia (lung infection). On May 1, 2025, Resident 7 had a dental visit, for a comprehensive oral evaluation. The dental evaluation indicated the following: .Patient completely edentulous (being without teeth) .complaining of localized pain on the left side of the face .mild tenderness to touch .complained of pain while eating .eating without her dentures. no redness, inflammation or sign of infection .recommend OTC (over-the-counter Ibuprofen (used to treat pain and inflammation) .Informed family to bring her dentures .her dentures are 5-[AGE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 4 of 11 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 07/07/2025 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)

F 0658 years old . Level of Harm - Minimal harm or potential for actual harm The nurse's notes dated June 16, 17, and 18, 2025, indicated Resident 7 complained of pain on the left side of her gum and received pain medication as ordered. Residents Affected - Few The physician's orders for May, June and July 2025, did not indicate an order for Orajel. On July 2, 2025, at 12:48 p.m., the Director of Nursing (DON) was interviewed. She stated there should be no medication stored at the resident's bedside. She stated licensed staff should conduct a self administration of medication assessment and evaluation prior to the resident's self-administration of medication to determine the resident's capacity to administer the medication. She stated the physician will be notified of the result of the assessment and staff will obtain a physician's order for the medication and self-administration of the medication. A review of the facility's policy and procedure titled, Storage of Medications, dated November 2024, indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . A review of the facility's policy and procedure titled, Administering Medications, dated April 2024, indicated, .Residents may self-administer their own medications only if the attending physician, in conjunction with the disciplinary care planning team, has determined that they have the capacity to do so safely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 5 of 11 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 07/07/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one resident of two residents (Resident 6) when:1.The physician was not contacted when Resident 6 blood sugar was below ordered parameters.2. Resident 6 received hypertension (high blood pressure) medication when blood pressure was below physician ordered parameters. This failure had the potential for Resident 6 to have adverse effects of hypoglycemic (low blood sugar) and hypotension (low blood pressure). Residents Affected - Few Findings:1. On July 1, 2025, at 1:13 p.m., a review of Resident 6's admission record indicated the resident was admitted into the facility on April 29, 2025, with the diagnoses which included osteomyelitis (bone infection), diabetes mellitus (high blood sugar), hypertension (high blood pressures).A review of Resident 6's medication administration record (MAR) for the month of June 2025, indicated the following:June 22, 2025, the 9 am dose of Losartan was administered with BP (blood pressure) indicating 108/54.June 22, 2025, the 9 am dose of Metoprolol was administered with BP indicating 108/54.June 13, 2025, the 6:30 am BS (blood sugar) indicated 62. The physician order dated June 6, 2025, indicated Losartan Potassium Oral Tablet give 12.5 mg (mg-a unit of measurement) .by mouth one time daily .hold if SBP (systolic blood pressure- top number of blood pressure reading) less than 110 .The physician order dated June 6, 2025, indicted Metoprolol ER (er-extended release) 24-hour 25 mg (mg - a unit of measurement) .1 tablet by mouth onetime daily .hold if SBP less than 110 .The physician order dated June 6, 2025, indicated Humalog injection solution 100 units/mL (mL- a unit of measurement) .inject per sliding scale .BS less than 70 or greater than 400 call MD (physician) .On July 3, 2025, at 10:33 a.m., a concurrent interview and record review was conducted with LVN 2. LVN 2 stated the facility process for hypertension medication is to take the resident BP and read it against the physician orders and document given meets physician orders or hold due to resident blood pressure being under physician order parameter. LVN 2 stated on June 6, 2025, at 9 am, Resident 6's BP was 108/54 below the physician order parameter for hypertension medication. LVN 2 stated Resident 6 hypertension medications of Losartan and Metoprolol should have been held. LVN 2 further stated Resident 6 should not have received his 9 am dose of Losartan and Metoprolol. LVN 2 stated the facility process for BS less than 70 is to notify the physician. LVN 2 stated Resident 6 BS on June 13, 2025, indicated 63. LVN 2 stated physician should have been notified. LVN 2 stated there is no documented evidence the nurse contacted the physician for Resident 6 BS of 63. LVN 2 further stated the physician should have been contacted and nursing interventions should have been provided to Resident 6 to ensure his blood sugar increase to physician ordered parameters.On July 3, 2025, at 11:51 a.m., a concurrent record review and interview was conducted with the DON. The DON stated the facility process for medication administration is to follow the physician orders. The DON stated on June 6, 2025, at 9 am, Resident 6's BP was 108/54 below the physician order parameter for hypertension medication. The DON stated Resident 6 hypertension medications of Losartan and Metoprolol should have been held. The DON further stated Resident 6 should not have received his 9 am dose of Losartan and Metoprolol. The DON stated the facility process for BS less than 70 is to notify the physician. The DON stated on June 13, 2025, Resident 6 BS indicated 63. The DON stated the physician should have been notified. The DON stated there is no documented evidence the nurse contacted the physician for Resident 6 BS of 63. The DON further stated the physician should have been contacted and nursing interventions should have been provided to Resident 6 to ensure his blood sugar increase to the physician order parameter.2. On July 7, 2025, Resident 9's medical record was reviewed. The physician's order, dated May 20, 2025, indicated .hydrALAZINE HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth three times a day related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 6 of 11 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 07/07/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ESSENTIAL (PRIMARY) HYPERTENSION . HOLD SBP < (less than) 110 OR HR (heart rate) <60 .The facility document titled, MEDICATION ADMINISTRATION RECORD, dated July 7, 2025, indicated that LVN 3 gave Hydralazine to Resident 9 on June 3, 2025 with a blood pressure reading of 96/64, which was below the medication order's parameter of holding Hydralazine with a SBP less than 110. On July 7, 2025 at 8:40 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 confirmed that she had given Hydralazine to Resident 9 on June 3, 2025. LVN 3 stated that prior to giving blood pressure medications, she should check vital signs (temperature, pulse, respirations and blood pressure) and ensure that they are within parameters. LVN 3 stated that the medication should not have been given because Resident 9's blood pressure was not within the medication order's parameters. LVN 3 stated that the medication could have caused Resident 9's blood pressure to drop even lower.A review of the facility policy and procedure titled, Administering Medications, revised April 2024, indicated .Medications are administered in accordance with prescriber orders .if dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication will contact the prescriber .The following information is checked/verified for each resident prior to administering medications .Allergies to medications .and .Vital signs, if necessary . Event ID: Facility ID: 555331 If continuation sheet Page 7 of 11 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 07/07/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: Residents Affected - Some 1. For Resident 7, Certified Nursing Assistant (CNA) 2 failed to use the disposable gown provided for Enhanced Barrier Precautions (EBP - infection prevention practices using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug resistant organisms [MDRO] - a germ that is resistant to many antibiotics) when providing direct care; and 2. For Residents 397, 9, 5, and 399, Licensed Vocational Nurse (LVN) 4 and LVN 1, failed to properly clean and disinfect shared medication tray, shared glucometer (blood glucose device that measures and displays the amount of sugar in the blood), the shared stethoscope (a device used to listen to sounds within the body, primarily the heart, lungs and bowels) and the blood pressure cuff (an inflatable cuff used to measure blood pressure) according to the disposable wipe manufacturer's specified contact time (the time the resident's equipment was to be in contact with the disposable wipes to kill microorganisms (bacteria, virus, algae, and fungi). These failures had the potential for vulnerable residents to be exposed to cross-contamination and the development of infection. Findings: 1.On July 1, 2025, at 3:33 p.m., Resident 7 was observed with an EBP sign outside her room. Resident 7 was receiving direct care from a facility staff member (CNA 2), with the curtain closed. The staff member (CNA 2) was observed opening the curtain holding a soiled diaper in his hand. He was not wearing a disposable gown. During a concurrent interview CNA 2 stated he cleaned Resident 7 and changed Resident 7's diaper. He stated he did not wear the disposable gown provided for EBP residents. He stated he saw the sign but did not look which resident was listed for EBP. CNA 2 stated he was supposed to use the disposable gown from the linen closet. He stated he should have put on the disposable gown prior to entering the room of Resident 7. On July 1, 2025, at 3:52 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated CNA 2 should have put on the disposable gown prior to proving care to Resident 7. On July 1, 2025, at 4:29 p.m., the Infection Preventionist (IP) was interviewed. The IP stated CNA 2 should have followed the EBP protocol. On July 2, 2025, at 12:48 p.m., the Director of Nursing (DON) was interviewed. The DON stated CNA 2 should have checked which resident was on EBP and should have used the disposable gown prior to giving care to Resident 7. A review of Resident 7's record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included MDRO infection, urinary tract infection ( UTI - bladder infection), and Chronic Obstructive Pulmonary Disease (COPD- lung disease). Resident 7 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 8 of 11 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 07/07/2025 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)

F 0880 alert and able to verbalize her needs. Resident 7 needed assistance with her activity of daily living (ADL). Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated August 2024, indicated, Enhanced barrier precaution (EBPs) are utilized to prevent the spread of multi-drug resistant organism (MDRO) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions .Gloves and gown are applied prior to to performing the high contact resident care activity . Residents Affected - Some 2. A review of the manufacturer's instructions for contact time of the Sani-Cloth Disposable wipe, indicated, .Contact time .thoroughly wet surface. Allow surface to remain visibly wet for two minutes. Let air dry . 2a. During the medication pass observation on July 3, 2025, at 11:08 a.m., for Resident 397, Licensed Vocational Nurse (LVN) 4 was observed wiping the shared medication tray using the disposable Sani-Cloth Germicidal Disposable Wipe, one time, and the shared glucometer, with another Sani-Cloth wipe once, and waited for the equipment to air dry. After performing the blood glucose check for Resident 397, LVN 4 was observed wiping the medication tray and the shared glucometer once and waited for the equipment to air dry. LVN 2 did not disinfect the shared equipment in accordance with the manufacturer's specified contact time of two minutes. 2b. During the medication pass observation on July 3, 2025, at 11:28 a.m., for Resident 9, LVN 4 was observed wiping the shared medication tray and the shared glucometer using the Sani-Cloth Germicidal Disposable wipe once and waited for the equipment to air dry. After checking Resident 9's blood sugar, LVN 4 was observed wiping the shared medication and the shared glucometer once and left the equipment to air dry on top of the medication cart. LVN 4 did not disinfect the shared equipment in accordance with the manufacturer's specified contact time of two minutes. During a concurrent interview and review of the Sani-Cloth Germicidal Disposable Wipe instruction, on July 3, 2025, at 11:33 a.m., with LVN 4, LVN 4 stated she used the disposable wipe to clean and disinfect the medication tray and the glucometer and waited two minutes to air dry. LVN 4 stated she was not aware the equipment had to be wet for two minutes, and air dry after. 2c. During the medication pass observation on July 3, 2025, at 11:51 a.m., for Resident 5, LVN 1 was observed using the medication tray and the shared glucometer to check Resident 5's blood glucose. LVN 1 did not sanitize the medication tray and the shared glucometer. After LVN 1 checked Resident 5's blood glucose, LVN 1 was observed wiping the medication tray and the shared glucometer with the Sani-Cloth disposable wipe once and placed it on top of the medication cart to air dry. LVN 1 did not disinfect the medication tray and the shared glucometer in accordance with the manufacturer's specified contact time of two minutes. 2d. During the medication pass observation on July 3, 2025, at 1:15 p.m., for Resident 399, Resident 399's blood pressure was taken by LVN 1. LVN 1 was observed wiping the blood pressure cuff and the stethoscope using the disposable Sani-Cloth wipe. LVN 1 did not disinfect the stethoscope and the blood pressure cuff in accordance with the manufacturer's specified contact time of two minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 9 of 11 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 07/07/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and review of the facility's Sani-Cloth Germicidal Disposable wipe instruction, on July 3, 2025, at 1:30 p.m., with LVN 1, LVN 1 stated he was confused about the Sani-Cloth wipe instruction of the two minutes contact time. LVN 1 stated he did not thoroughly keep the glucometer and the blood pressure cuff wet using the Sani-Cloth wipes for two minutes. On July 3, 2025, at 2:05 p.m., a concurrent interview and review of the Sani-Cloth Germicidal Disposable wipe instruction was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP). The IP stated the nursing staff were expected to clean and disinfect the shared equipment after use and before the next resident using the Sani-Cloth disposable wipe. The IP stated nursing staff should wipe the shared equipment for two minutes according to the manufacturer's instruction. The DON reviewed the manufacturer's instruction outside the Sani-Cloth wipe container. The DON acknowledged the contact time for disinfecting using the Sani-Cloth wipe was two minutes for the surface to remain wet. She stated it was important to follow the specified contact time of the disposable wipe to prevent cross contamination. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2023, indicated, .Reusable resident equipment will be decontaminated .between residents according to manufacturer's instructions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 10 of 11 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 07/07/2025 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms: 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34). Findings: On June 30, 2025, at 2:38 p.m., a concurrent observation and interview was conducted with Resident 11 in room [ROOM NUMBER] A. Resident 11 was observed awake and oriented sitting in bed watching television. Resident 11 stated he did not feel the room size interfered with his care. On June 30, 2025, at 3:47 p.m., a concurrent observation and interview was conducted with Resident 34 in room [ROOM NUMBER] A. Resident 11 was observed in a wheelchair self-propelling himself into room [ROOM NUMBER]. Resident 34 stated he has no issues with his room size and stated the size of the room does not interfere with his care or ability to operate his wheelchair within his room. On June 30, 2025, at 3:50 p.m., a concurrent observation and interview was conducted with the family member of Resident 39 in room [ROOM NUMBER] B. Resident 39 was observed in bed and family member was observed walking around room [ROOM NUMBER] placing items on Resident 39 bedside table. Resident 39 family member stated the room size has not interfered with Resident 39 care. During the following survey dates June 30, July 1, July 2, July 3, and July 7, 2025, the above listed rooms were observed at different times of the day. There were no observed adverse effects that impacted the quality of life for the residents who resided in the rooms. On June 30, 2025, the Administrator submitted the requirements for the request to continue room waivers for rooms 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34. The survey team recommends the room variance continue, provided the health and safety of the residents who reside in the above-mentioned rooms are not adversely affected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555331 If continuation sheet Page 11 of 11