Inspection·September 5, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) or their RP was informed of a new medication ordered by the physician. Residents Affected - Some * The facility failed to ensure Resident 1 or Resident 1's RP was notified of a new physician's order for Levaquin (antibiotic medication). This failure had the potential for Resident 1 and their responsible party to not be informed of the medications and their potential side effects. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised May 2017 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a change in the resident's physical, mental, or psychosocial status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. On 9/4/24 at 0950 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was diagnosed with pneumonia and prescribed Levaquin medication at the facility. Family Member 1 stated the responsible party was not notified of the new medication, until Resident 1 began vomiting. Medical record review for Resident 1 was initiated on 9/4/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 8/13/24, showed Resident 1 had the capacity to make medical decisions. Review of Resident 1's POLST dated 8/12/24, showed Resident 1 had a legally recognized decisionmaker. Review of Resident 1's Advance Directive dated 8/15/24, showed Resident 1 had a surrogate decisionmaker that was listed as the responsible party. Review of Resident 1's Order Summary Report dated 8/19/24, showed a physician's order dated 8/15/24, to administer Levaquin 500 mg one tablet by mouth one time a day for lobar pneumonia for seven days. (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 09/05/2024 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)