Inspection·July 24, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident's physician was promptly notified of the resident's unwitnessed fall for one of three sampled residents (Resident 1) as per the facility's P&P. This failure had the potential to result in inadequate care for the Resident 1. Findings: Review of the facility's P&P titled Falls Management Program revised 1/2019 showed a definition of a fall included: - When a resident, family member or staff member said a fall occurred. - When a person was found on the floor, regardless of whether any injury resulted. - An occasion on which residents lowered themselves to the floor. -When the resident had to be lowered to the floor by a staff member to prevent a fall. The P&P further showed the licensed nurse will notify the resident's attending physician and responsible party of the fall incident and the resident's status. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 showedthe facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status such as changes in level of care, billing and payments, resident rights, etc.). The P&P further showed the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Closed medical record review for Resident 1 was initiated on 7/23/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 5/10/24. Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS score of 13 indicating the resident was cognitively intact. Review of Resident 1's eINTERACT Change in Condition Evaluation V5 dated 5/10/24, showed Resident 1 had an unwitnessed fall at 0145 hours with no injury. The resident stated she did not hit her head. (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: 555462 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 07/24/2024 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)