Health inspection·April 4, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a written Notice of Discharge (a notice informing the resident of their discharge date , and their rights to appeal the discharge) was provided to the resident and/or resident representative prior to the date of discharge from the facility, for two of three residents reviewed (Residents 1 and 2). In addition, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman) was provided a copy of the written Notice of Discharge for Residents 1 and 2. These failures could have resulted in Residents 1 and 2 not to be aware of their rights to appeal the discharge and the Ombudsman to not be able to inform the residents of their rights and options to appeal prior to the resident being discharged . Findings: On March 13, 2024, at 7:55 a.m., an unannounced visit was conducted with the facility to investigate a quality of care issue. 1. On March 13, 2024, a review of Resident 1's face sheet, indicate the resident was admitted to the facility on [DATE], with a fracture (broken bone) of the right pubis (pelvis). A review of Resident 1's physician's orders, dated December 12, 2023, at 2:41 p.m., indicated, .LCD (Last Covered Day) 12/14 (December 14, 2023), DC (Discharge) 12/15 (December 15, 2023) . A review of Resident 1's Discharge Instruction, effective date December 12, 2023, indicated Resident 1 signed the discharge instructions on December 15, 2023. A review of Resident 1's Notice of Transfer/Discharge, dated December 15, 2023, indicated Resident 1 signed the notice of transfer on December 15, 2023. A review of Resident 1's Transmission Log, dated December 15, 2023, at 11:15 a.m., indicated, a confirmation of resident's notice of discharge was successfully faxed to the Ombudsman's office on December 15, 2023 (the day of the resident's her discharge). 2. On March 13, 2024, a review of Resident 2's face sheet, indicated Resident 2 was admitted to the facility on [DATE], with a fracture of his left Ilium (upper pelvis). A review of Resident 2's physician's orders, dated February 28, 2024, indicated, .LCD 2/29 (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: 555353 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 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)