Inspection·October 10, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few speak and understand very limited English. Resident 2 was asked how long she has been staying in the facility and the reason for her stay in the facility. Resident 2 gestured with her hand and stated, No and was not able to answer. Resident 2 was interviewed with the assistance of the translation services via phone for Vietnamese language . Resident 2 was asked how she communicated her daily needs to the staff and how the staff understood her since Resident 2 spoke mainly Vietnamese and Cantonese. Resident 2 stated there were no Vietnamese or Cantonese speaking staff to translate, communication board provided and available to use in her room, and the facility staff did not use any translator via telephone. In addition, Resident 2 stated since no one can understand, speak, or translate in her language, she had to wait for her family to arrive and communicate her needs. On 10/8/25 at 1132 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 1. LVN 1 was asked which was the preferred language of Resident 2 and how the resident communicated her daily needs. LVN 1 stated Resident 2 spoke Chinese or Korean language and able to express her needs. LVN 1 stated Resident 2's family member visited the resident every day from morning until bedtime, at around 2100 hours. LVN 1 was asked how the facility staff would understand and communicate with Resident 2 when the family member was not around or between the hours of 2200 to 0700 hours. LVN 1 stated if a family member was not present, there were staff from rehabilitation department who can translate, use a communication board, or use the facility's telephone to translate. In addition, LVN 1 was asked to show Resident 2's communication board. LVN 1 was followed to Resident 2's room to look for the communication board consistent with the resident's preferred language; however, LVN 1 failed to show a communication board was present and available for Resident 2 to use to communicate her needs. LVN 1 stated the communication board was not necessary to be available inside Resident 2's room. Furthermore, when LVN 1 was asked how to use the language line using the facility's telephone, LVN 1 was not able to show how to use the language line via facility's telephone and walked away. On 10/8/25 at 1140 hours, an observation and concurrent interview for Resident 2 was conducted with CNA 2. CNA 2 was asked to show the communication board for Resident 2. CNA 2 was observed looking for the communication board inside Resident 2's room. CNA 2 stated she could not find the communication board and was not available inside Resident 2's room. CNA 2 stated if any resident was not able to communicate their needs, the resident's needs might not be met. On 10/8/25 at 1145 hours, an observation and concurrent interview for Resident 2 was conducted with the DSD. The DSD stated the nurses use the language line solutions and there were staff who spoke Korean. The DSD was asked to show the communication board inside Resident 2's room; however, the DSD failed to show the communication board was available for Resident 2 and facility staff to use. On 10/8/25 at 1217 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 2 spoke Chinese and Vietnamese language and very limited English. Family Member 1 stated Resident 2's family member visited daily and stayed until 2200 hours so the family member can be there to communicate Resident 2's daily needs because the resident could not understand English. However, during the family's absence or night hours (2300-0700 hours), Family Member 1 stated she was concerned if Resident 2's needs were met because she did not know how the facility staff could understand Resident 2 and vice versa. Family Member 1 was asked how the facility staff communicated with Resident 2, if facility staff have used a communication board or a language line to translate. Family Member 1 stated she has not seen a communication board in Resident 2's preferred language(s) provided and available in the room, nor did the facility staff have used a communication board during Resident 2's stay. In addition, Family Member 1 stated she has not observed any facility staff using the language line translation with Resident 2. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 2 of 10 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 10/10/2025 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)

F 0558 findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 3 of 10 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 10/10/2025 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)

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 comprehensive care plans were developed to reflect the individual care needs for one of four sampled residents (Resident 3) reviewed for care plans. * The facility failed to ensure a care plan was developed for the use of the anticoagulant medication ordered by the physician. This failure had the potential for the resident to not be provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Plans revised 12/2016 showed the following:- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; and - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Medical record review for Resident 3 was initiated on 10/10/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 10/6/25, showed a physician's order dated 10/5/25, for apixaban (medication to prevent blood clots) oral tablet 2.5 mg, to give one tablet by mouth one time a day for Atrial Fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly). Review of Resident 3's H&P examination dated 10/7/25, showed the resident had the capacity to understand and make decisions. Further review Resident 3's medical record failed to show a care plan was developed to address the use of the anticoagulant medication. On 10/10/25 at 1007 hours, an interview and concurrent health record review for Resident 3 was conducted with RN 1. RN 1 verified there was a physician's order for the apixaban medication. RN 1 also verified there was no care plan developed for the use of the anticoagulant medication for Resident 3. RN 1 stated she was not responsible for developing care plans for the use of the anticoagulant medication upon admission. In addition, RN 1 stated the DON, ADON, and MRD were responsible for auditing new admissions for completion. On 10/10/25 at 1212 hours, an interview was conducted with LVN 2. LVN 2 was asked about the importance of initiating a care plan for a resident receiving an anticoagulant. LVN 2 stated the anticoagulant medications must have a care plan to show goals and interventions such as monitoring for side effects and re-assess outcomes. On 10/10/25 at 1251 hours, an interview was conducted with the MRD. The MRD stated she would review and audit new admission charts for the completion of medication entries, baseline assessments, and care plans; however, the ADON and MDS Coordinator would be responsible in reviewing and initiating the care plan for medications. On 10/10/25 at 1403 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator was asked when the care plan for anticoagulant use must be initiated for Resident 3. The MDS Coordinator stated the care plan for the use of anticoagulant must be initiated as soon as possible. The MDS Coordinator verified Resident 3's medical record failed to show a care plan for the use of anticoagulant was developed. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555462 If continuation sheet Page 4 of 10 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 10/10/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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 provide the necessary care and services to attain or maintain the highest practicable well-being for one of four sampled residents (Resident 1). * The facility failed to ensure the follow-up assessment, physician notification, and documentation were completed when Resident 1 had low pulse rate and poor oral intakes. These failures posed the risk of the resident not receiving the appropriate care and delay in the provision of care to the resident.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the following:- the nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition;- a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention and impacts more than one area of the resident's health status;- prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form; and- the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 10/9/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 14 (cognitively intact). Review of Resident 1's H&P examination dated 9/10/25, showed Resident 1 had the capacity to understand and make decisions. a. According to AHA (American Heart Association) document titled Bradycardia: Slow Heart Rate revised on 9/25/24, showed bradycardia is a heart rate that is too slow, usually less than 60 beats per minute. Review of Resident 1's admission and Baseline Care Plan dated 9/5/25, showed a blood pressure of 118/79 mmHg and pulse rate of 76 bpm (beats per minute). Review of Resident 1's Weights and Vital Summary for September 2025 showed the following pulse rate readings:- dated 9/9/25 at 0930 hours, the pulse rate was 55 bpm;- dated 9/9/25 at 1645 hours, the pulse rate was 50 bpm; and- dated 9/13/25 at 2026 hours, the pulse rate was 57 bpm. Review of Resident 1's medical records failed to show documentation if the follow up assessments were done and the physician was notified of the low pulse rate. On 10/9/25 at 1429 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 1's abnormal pulse rates dated 9/9 and 9/13/25. RN 1 verified Resident 1's medical record it failed to show the follow up assessments, interventions, notification of the physician, and documentation when Resident 1 had low pulse rate. RN 1 was asked what she considers a change in condition in a resident and RN 1 stated it could be abnormal vital signs, altered level of consciousness, weakness, skin problems, fall, increased pain, and any changes in resident's condition from his or her baseline. b. Review of Resident 1's Meal Intake from 9/5 to 9/12/25, showed the percentage of the meals eaten by Resident 1 on the following dates:- dated 9/13/25, breakfast = 0 - 25%, lunch = 26-50%, dinner = 26 - 50%;- dated 9/14/25, breakfast = 25 - 50%, lunch = 0-25%, dinner = 0 - 25%;- dated 9/15/15, breakfast = 0 - 25%, lunch = 0-25%, dinner was refused;- dated 9/16/25 breakfast = 0 - 25%, lunch = 0-25%, dinner = 51-75%; and- dated 9/17/25 breakfast = 0 - 25%, lunch = 0 - 25%, dinner = resident not available. On 10/10/25 at 0930 hours, a follow-up interview and concurrent medical record review was conducted with RN 1. Resident 1's meal intakes dated 9/13-9/17/25, was reviewed with RN 1 which showed decreased meal consumption with refusal. RN 1 verified there was no documented evidence if the follow up assessments, physician notification, change of condition evaluation, and care plan was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 5 of 10 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 10/10/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete developed when Resident 1 had poor meal intake. Furthermore, RN 1 stated the negative outcome would cause Resident 1's condition to decline because he was not consuming the appropriate nutrients. On 10/10/25 at 1100 hours, an interview and concurrent medical record review were conducted with CNA 1. CNA 1 verified Resident 1's poor meal intakes dated 9/13 to 9/17/25. CNA 1 stated Resident 1 became weaker, refused to participate with activities, and refused to get up in wheelchair after four to five days of admission. CNA 1 stated she reported Resident 1's change of condition including the significant decrease in meal intake to the charge nurses. On 10/10/25 at 1212 hours, a telephone interview was conducted with LVN 2. LVN 2 was asked what she would consider a change of condition, and stated fever, abnormal labs, decline in activities of daily living (ADL), new pain or increase pain, ALOC (altered level of consciousness), abnormal vital signs blood pressure below100/60 mmHg or pulse rate below 60 bpm or above 90 bpm, and refusal of meals or below 25% meal consumption. LVN 2 stated the assigned licensed nurse must assess the resident, complete the change of condition evaluation, notify the physician, notify responsible party or family, initiate a care plan, add to the alert charting, and document the monitoring every shift for 72 hours. Furthermore, LVN 2 stated the negative outcome would be not being able to provide the appropriate quality care and monitoring for the resident's change of condition and resident's condition could become worse. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated abnormal vital signs were not a significant change and not considered a COC (Change of Condition). The DON stated she did not expect her licensed nurses to do a follow up entry when there are abnormal vital signs and after providing interventions to reflect resident's current condition. The DON was asked how she would know when the resident's abnormal vital signs (pulse rate) improve if there were no follow up assessments and documentation of the outcome, the DON stated the nurses cannot document every hour since they had a lot of residents. The DON stated she considered a significant COC if the resident's meal intake was 0 - 25% consecutively with refusal for three to four days. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555462 If continuation sheet Page 6 of 10 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 10/10/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **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 implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one of four sampled residents (Resident 3). * The facility failed to ensure CNA 3 wore the appropriate PPE when providing high-contact resident care for Resident 3. This failure had the potential to transmit communicable disease to other residents throughout the facility.Findings: Review of the facility's P&P titled EBP dated 6/20/24, showed the following:- EBP used in conjunction with the standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing reduce transmission;- facility staff shall post a visual alert by the resident's door indicating the high-contact resident care activities requiring the use of gowns and gloves for residents with the following criteria for the duration of a resident's stay in the facility or until resolution of the targeted criteria that placed them at higher risk like indwelling medical devices with or without secretions or excretions even if the resident is not known to be infected or colonized with a MDRO such as central lines, urinary catheters, feeding tube, and tracheostomies;- the facility shall provide required PPEs and alcohol-based hand rub (ABHR) readily available, and PPEs may be discreetly accessible to staff to use to help maintain a home-like environment as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; and- facility staff shall perform hand hygiene and will don gown and gloves before performing the following high-contact resident care activities like dressing, bathing/showering/transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy or ventilator, and wound care on chronic wounds requiring a dressing. Medical record review for Resident 3 was initiated on 10/10/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary report showed a physician's order dated 10/6/25, for EBP related to the indwelling devices. Review of Resident 3's H&P examination dated 10/7/25, showed Resident 3 had the capacity to understand and make decisions. On 10/10/25 at 0855 hours, an observation of Resident 3 and concurrent interview was conducted with CNA 3. Resident 3's door had signage indicating the resident's roommate was on EBP. Upon entering Resident 3's room, CNA 3 was observed wearing only gloves and transferred Resident 3 to the wheelchair. CNA 3 stated he assisted Resident 3 with the morning care like brushing his teeth and transferring to the wheelchair in preparation for dialysis pick up. CNA 3 stated he was aware Resident 3 has dialysis and verified he wore only gloves. CNA 3 verified the signage outside the door showed Resident 3's roommate was on EBP and should have worn the proper PPE. On 10/10/25 at 0904 hours, an observation, interview and concurrent medical record review for Resident 3 was conducted with RN 3. RN 3 verified Resident 3 had a physician's order for EBP related to the indwelling device due to having a central line for dialysis access. RN 3 stated the EBP sign outside Resident 3's room should have shown Resident 3 was also on EBP per the physician's order. RN 3 stated the sign must be updated by the DSD because the DSD was responsible for checking and updating residents who have orders for EBP. RN 3 stated all the staff should don gowns and gloves during high-contact resident's care activities like morning care and transfers to prevent the spread of infection. On 10/10/25 at 1350 hours, an interview was conducted with the IP nurse. The IP nurse stated for any residents who have an order for EBP, all staff must wear gloves and gown when providing morning care and transferring the residents. In Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 7 of 10 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 10/10/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete addition, the IP nurse stated she was responsible for placing the EBP signage and PPE carts with the help of her assistant. Furthermore, the IP nurse stated the negative outcome of the staff not following EBP would be spreading the staff's germs to the residents. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON stated it was important for all the staff to follow the EBP to prevent direct caregiver transmission of any infection to the residents. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555462 If continuation sheet Page 8 of 10 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 10/10/2025 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)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for one of four sampled residents (Resident 2) and one nonsampled resident (Resident A) reviewed for grab rail use. * The facility failed to ensure the entrapment assessment of the grab rails were accurately completed for Residents 2 and A. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.Findings: According to the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/06, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is potential for entrapment are:- Zone 1: within the rail;- Zone 2: under the rail, between the rail supports or next to a single rail support;- Zone 3: between the rail and the mattress;- Zone 4: under the rail, at the ends of the rail;Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and- Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety revised 12/2007 showed the following:- to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches like inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks and review that gaps within the bed system are within the dimensions established by the FDA; and- the maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. a. Medical record review for Resident 2 was initiated on 10/9/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary report showed a physician's order dated 9/29/25, for the bilateral grab rail for ease and comfort in bed mobility, transfer, and repositioning as enabler every shift. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 12, indicating moderate cognitive impairment. On 10/8/25 at 1117 hours, an observation of Resident 2's bed and concurrent interview was conducted with CNA 2. Resident 2 was not present in her room. Resident 2's bed had elevated halo style bilateral grab rails. CNA 2 stated Resident 2 used the bilateral grab rails to transfer. On 10/8/25 at 1125 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was awake, alert, and sitting up in wheelchair in the lobby. Resident 2 stated she used the grab rails from the bed to transfer to the wheelchair. b. Medical record review for Resident A was initiated on 10/10/25. Resident A was admitted to the facility on [DATE]. Review of Resident A's H&P examination dated 9/10/25, showed Resident A had the capacity to understand and make decisions. Review of Resident A's Order Summary report showed a physician's order dated 9/12/25, for the bilateral grab rail for ease and comfort in bed mobility, transfer, and repositioning as enabler every shift. Review of Resident A's MDS assessment dated [DATE], showed Resident A's BIMS score was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555462 If continuation sheet Page 9 of 10 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 10/10/2025 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)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 15, indicating cognitively intact. On 10/10/25 at 1455 hours, an observation and concurrent interview was conducted with the DON. Resident A's bed had elevated bilateral grab rails. The DON verified the findings and stated Resident A would use the bilateral grab rails for bed mobility and during physical or occupational therapy treatments. On 10/10/25 at 1503 hours, an interview and concurrent facility document review was conducted with the Maintenance Supervisor. - Review of Resident 2's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed Zones 1 through 7 were marked pass. Further review of Resident 2's Bed Rail 7 Zones Entrapment Assessment showed must assess the entrapment for Zones 1, 3, 6, and 7. However, Zones 2, 4, and 5 should have been marked as not applicable (N/A). - Review of Resident A's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed Zones 1 through 7 were marked pass. Further review of Resident A's Bed Rail 7 Zones Entrapment Assessment showed must assess the entrapment for Zones 1, 2, 3, 6, and 7. However, Zones 4 and 5 should have been marked as not applicable (N/A). The Maintenance Supervisor stated he was responsible for completing the entrapment assessments of the grab rails after receiving the physician's order to apply the grab rails from the ADON. The Maintenance Supervisor stated he used the tape measure to measure the zones and referred to the FDA Bed System guide for entrapment. The Maintenance Supervisor was asked to explain how to measure Zone 5 using the facility's guide of Bed Rail 7 Zones Entrapment Assessment guide with photo of the zones. The Maintenance Supervisor stated for Zone 5, he measured from the top of the rail to the top of the mattress. The Maintenance Supervisor was informed the correct and accurate process to measure Zone 5 was to measure the length of between split bed rails, which both Residents 2 and A have bilateral upper grab rails only. The Maintenance Supervisor verified the above findings and stated the entrapment assessments were inaccurate. On 10/10/25 at 1536 hours, an interview was conducted with the DON. The DON was informed of Resident 2 and A's entrapment assessments, which all the zones were marked pass. The DON stated at least the facility did more than it was supposed to assess. The DON verified the Maintenance Supervisor's assessments were inaccurate and verified the findings. Event ID: Facility ID: 555462 If continuation sheet Page 10 of 10