Health inspection·April 12, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident #17's admission Record revealed the facility originally admitted the resident on 05/06/2019 and readmitted the resident on 10/03/2022. The admission Record revealed the resident had diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or partial paralysis of one side of the body) following non-traumatic intracerebral hemorrhage (blood pooling in the tissue of the brain) affecting the right dominant side, Huntington's disease, and cognitive communication deficit. Residents Affected - Few A review of Resident #17's quarterly MDS, with an Assessment Reference Date (ARD) of 01/13/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #17 had no falls since admission. A review of Resident #17's IDT [Interdisciplinary Team] - Incident Review, dated 11/04/2023, indicated staff found Resident #17 on the floor next to the door of their room, and their bed was in the lowest position at the time. The document indicated that staff assessed the resident and discovered no injuries, assisted the resident back to bed, and applied a bed alarm and bilateral landing pads. During an interview on 04/12/2024 at 10:17 AM, the MDS Coordinator stated she reviewed the resident's medical record over the previous quarter when completing the MDS. The MDS Coordinator further stated that Resident #17's fall in November 2023 should have been captured on the 01/13/2024 assessment, but it was not. Based on record reviews, interviews, and facility document and policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 1 (Residents #37) of 5 sampled residents reviewed for unnecessary medications and 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, the facility failed to ensure Resident #37's use of psychotropic medications and Resident #17's fall event was accurately coded on their MDS assessments. Findings included: A review of a facility policy titled Resident Assessments, revised in September 2023, revealed, 8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. 1. A review of Resident #37's admission Record indicated the facility admitted the resident on 10/20/2023 with diagnoses that included alcoholic cirrhosis of the liver with ascites (abnormal fluid buildup in the abdominal cavity), mood disorder due to known physiological condition and anxiety (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 9 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 04/12/2024 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)