Inspection·June 13, 2024

F 0645 days, the facility should resubmit a new level I screening on the 31st day. Level of Harm - Minimal harm or potential for actual harm Resident #107's medical record revealed no evidence to indicate a new level I screening was submitted after the 31st day of the resident's admission to the facility. Residents Affected - Few The facility's Resident List Report, dated 06/10/2024, revealed Resident #3 and Resident #107 were residents of the facility. During an interview on 06/11/2024 at 10:46 AM, the Director of Nursing (DON) stated she was not aware of any residents that required a new Level I PASARR being submitted after 30 days. The DON stated the facility was a short-term facility, and most residents discharged within 24-28 days after admission. During an interview on 06/11/2024 at 11:36 AM, the Assistant Director of Nursing (ADON) stated she oversaw the PASARR screenings to ensure they were completed for the residents. Per the ADON, if a resident remained in the facility after 30 days, it was her responsibility to ensure that a new level I was completed. The ADON stated Resident #3's and Resident #107's letters were not reviewed and the level I had not been resubmitted. During an interview on 06/11/2024 at 11:46 AM, the Social Service Director stated she was not aware of the requirement to resubmit a level I after the resident remained in the facility after 30 days. During an interview on 06/13/2024 at 8:34 AM, the Administrator stated he expected the staff would submit the level I PASARR by the day it was required. According to the Administrator, the nurses were responsible for completion of the level I PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 2 of 4 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 555462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Valencia Healthcare Center 25000 Calle DE Los Caballeros Laguna Hills, CA 92653 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, record review, and facility policy review, the facility failed to ensure a resident was monitored for psychotropic medication use and an order for a PRN (pro re nata, as needed) psychotropic medication was limited to 14 days for 1 (Resident #102) of 5 sampled resident reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, revealed, a. PRN orders for psychotropics medications are limited to 14 days. The policy specified, 13. Residents receiving psychotropic medications are monitored for adverse consequences, including: a. anticholinergic effects-flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation: b. cardiovascular effects-irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension: c. metabolic effectsincreased cholesterol and triglycerides, poorly controlled or unstable blood sugar, weight gain: d. neurologic effects-agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia, cerebral vascular events: and e. psychological effects- inability to perform ADLs [activities of daily living] or interact with others, withdrawal or decline from usual social patterns, decreased engagement in activities, diminished ability to think or concentrate. An admission Record revealed the facility admitted Resident #102 on 06/06/2024. Resident #102's care plan, initiated on 06/06/2024, revealed the resident had a diagnosis of acute renal failure. Interventions directed the staff to monitor/document/report as needed any signs/symptoms of depression. Resident #102's Order Summary Report, with active orders as of 06/12/2024, revealed an order dated 06/07/2024, for trazadone hydrochloride oral tablet 50 milligram one tablet by mouth as needed for depression manifested by the inability to sleep at bedtime. There was no end/stop date for the medication. Resident #102's Medication Administration Record, for 06/2024, revealed no evidence to indicate the staff monitored the resident for the side effects of the trazadone. During an interview on 06/12/2024 at 9:07 AM, Licensed Vocational Nurse (LVN) #1 stated PRN psychotropic medications should be ordered for 14 days only and the order should have a stop date on the 14th day. LVN #1 stated psychotropic medications must be monitored for signs and symptoms, behaviors, adverse effects, and the reaction to the medication. During an interview on 06/12/2024 at 9:56 AM, LVN #2 stated the nurses must monitor residents for the side effects of psychotropic medications. LVN #2 stated PRN psychotropic medications must have an end day after 14 days. During an interview on 06/12/2024 at 10:17 AM, the Director of Nursing (DON) stated once the nurse received an order from the physician for a PRN psychotropic medication, the order must include a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 3 of 4 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 555462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Valencia Healthcare Center 25000 Calle DE Los Caballeros Laguna Hills, CA 92653 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stop date after 14 days. The DON stated all residents who are ordered a psychotropic medication must be monitored for their behavior(s) and the side effects of the medication. During an interview on 06/13/2024 at 7:59 AM, LVN #3 stated he received the PRN psychotropic medication order for Resident #102. LVN #3 stated it was an oversight that he did not include an end/stop date for the medication for 14 days. LVN #3 stated he did not add the monitoring of the medication side effects and adverse effects to the resident's order as required by the facility. During an interview on 06/13/2024 at 8:40 AM, the Administrator stated he expected the facility staff to follow the proper protocols for all medications. During an interview on 06/13/2024 at 8:48 AM, the Nurse Practitioner (NP) stated the order for a PRN psychotropic medication should include a stop date after 14 days. The NP stated the facility should include monitoring the resident for behaviors and the side effects of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 4 of 4