Inspection·April 2, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facilityP&P review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was accurate and complete. * The facility failed to ensure Resident 1's admission to the facility, refusal of care, and discharge information was accurately and/or completely documented. This failure had the potential for Resident 1 to not receive the appropriate care and can negatively impact her overall health and wellbeing. Findings: Review of the facility's P&P titled admission Assessment and Follow-up: Role of the Nurse revised 9/2012 showed the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instrument, including the MDS. The section for Documentation showed the following information should be recorded in the resident's medical record: 1. The date and time the assessment was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All relevant assessment data obtained during the procedure. 4. How the resident tolerate the assessment. 5. Orders obtained from the physician. 6. The signature and title of the person recording the data. Review of the facility's P&P titled Charting and Documentation dated July 2017 showed all the services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The documentation of the procedures and treatments will include care-specific details, including:a. The date and time the procedure/treatment was provided;b. The name and title of the individual(s) who provided the care;c. The assessment data (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 04/02/2025 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)