Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valencia Gardens Health Care Center during CMS and state inspections, most recent first.
The facility did not provide discharge notices to the State LTC Ombudsman at the same time as two residents or their representatives received them. In both cases, the Ombudsman was notified several days after the residents were given their discharge notices, contrary to facility policy requiring same-day notification.
A resident with diabetes experienced a hypoglycemic episode with a blood sugar of 37. Although nursing staff reported providing orange juice and notifying the physician, there was no documentation in the medical record of the interventions or follow-up, contrary to facility policy and standard practice.
The facility failed to accurately account for controlled medications for three residents, leading to discrepancies between the Medication Count Sheets and MARs. Two tablets were unaccounted for one resident, while another had five tablets missing over two months, and a third resident had 15 tablets unaccounted for. The facility's process requires documentation of medication administration, which was not followed.
A resident with hypertension and COPD received Hydralazine Hydrochloride despite having systolic blood pressure readings below the physician-ordered threshold. The medication was administered multiple times from mid-May to early June, contrary to the order to hold it if the systolic blood pressure was less than 130. A nurse acknowledged the error, noting that the licensed nurses failed to follow the administration parameters and should have consulted the physician.
The facility failed to ensure dietary staff followed proper procedures, leading to potential food safety issues. Staff did not adhere to cleaning protocols, failed to document cooling processes, and lacked training in thermometer calibration. Additionally, incorrect use of sanitizer test strips and improper immersion of kitchenware in sanitizer were observed, risking foodborne illness and inadequate nutrition for residents.
The facility failed to meet the nutritional needs of three residents by not following prescribed dietary orders. A resident on a Fortified diet received diet Jello and insufficient dressing, another on a Controlled Carbohydrate Diet was served regular dessert, and a third requiring large portions received a regular portion. These discrepancies were confirmed by staff and the Registered Dietician, highlighting the importance of adhering to dietary orders.
The facility was found to have multiple deficiencies in kitchen sanitation and food storage practices. Staff failed to follow proper cleaning procedures for food preparation surfaces, leading to potential cross-contamination. Dust and debris were observed in various areas of the kitchen, and poor quality produce was found in storage. Additionally, kitchen appliances and utensils had visible buildup, and food items were improperly stored, with some left open and unlabeled. These issues were confirmed by the Dietary Services Supervisor and Registered Dietician, highlighting a failure to adhere to the facility's policies.
The facility failed to implement proper infection control practices, including the absence of Enhanced Barrier Precautions for a resident with a urinary catheter, improper disinfection of shared medical equipment, and incorrect cleaning of glucometers. These lapses were confirmed by staff interviews and were contrary to facility policies and CDC guidelines.
The facility failed to maintain kitchen equipment in a safe and clean condition, with issues such as ice buildup in the freezer, cracked and rusted shelves, and worn cutting boards. These deficiencies were confirmed by the DSS and RD, highlighting risks of contamination and bacterial growth.
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by a gnat in the dry storage room and four flies in the kitchen. The Dietary Services Supervisor noted that ripe bananas attract gnats, and a staff member mentioned that flies enter when the door is opened, with the ceiling fan being ineffective. The Registered Dietician confirmed the risk of cross-contamination. The facility's pest control policy indicates an ongoing program to keep the building free of pests.
A resident with severe cognitive impairment and multiple diagnoses was observed with an exposed urinary catheter drainage bag, lacking a dignity bag, in an LTC facility. A CNA acknowledged the oversight, and the DSD/IP confirmed the requirement for dignity bags to protect residents' privacy, as per the facility's policy on Resident Rights.
A resident's call light was not within reach, posing a risk of unmet needs. The resident, who uses a wheelchair and has a history of falling, confirmed the inaccessibility. A CNA and the DSD/IP acknowledged the call light should be accessible, aligning with facility policy.
A resident with prostate cancer and severe malnutrition was transferred to a hospital due to a decline in condition, but the facility failed to notify the resident's family member. The family member was unaware of the transfer and searched for the resident two days later. The facility's policy requires notifying a resident's representative of significant changes, which was not adhered to in this instance.
A resident with a history of CHF, MI, and a pacemaker was transferred to the hospital for chest pain and returned to the facility without an updated care plan. The facility did not revise the care plan with new goals and interventions, as confirmed by the RN Supervisor, despite policy requirements to do so after significant changes or readmissions.
The facility failed to document pacemaker information for two residents, leading to deficiencies in their care plans. One resident, with a history of heart issues, lacked pacemaker details in her record, while another resident's care plan omitted essential pacemaker and AICD information. The Registered Nurse Supervisor confirmed these omissions, which were against the facility's policy requiring comprehensive documentation.
A resident with COPD and CHF was administered oxygen without a physician's order, contrary to the facility's policy. Observations and staff interviews confirmed the resident used oxygen continuously since admission, but no order was documented. The facility's policy requires a physician's order for oxygen administration, which was not followed.
A medication error rate of 13.89% was identified in a LTC facility, involving two residents. An LVN misread blood pressure parameters, leading to the omission of prescribed blood pressure medications for one resident. Additionally, the LVN administered an incorrect dosage of escitalopram and failed to give other prescribed medications to another resident. The errors were acknowledged by the LVN and confirmed by the Registered Nursing Supervisor.
The facility did not meet the required bedroom space of at least 80 square feet per resident in 12 rooms. The Administrator acknowledged the deficiency and mentioned a waiver request. Observations showed no adverse effects on residents' quality of life, and a resident stated the room size did not interfere with care.
Failure to Timely Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was given to the resident or the resident's representative for two of six sampled residents. For one resident with cognitive communication deficit and muscle weakness, the discharge notice was given to the resident on May 7, 2025, but the notice was not sent to the Ombudsman until May 12, 2025, five days later. For another resident with acute osteomyelitis of the right ankle and a traumatic amputation of the right great toe, the discharge notice was provided to the resident and their representative on May 23, 2025, but the Ombudsman was not notified until May 26, 2025, three days later. The Social Services Director confirmed during interview and record review that the discharge notices were not sent to the Ombudsman on the same day as provided to the residents, as required. Facility policy states that the Ombudsman should be notified once the resident or representative signs the discharge notice, but this procedure was not followed in these cases.
Failure to Document Interventions for Hypoglycemic Event
Penalty
Summary
The facility failed to document the interventions provided to a resident who experienced hypoglycemia, with a recorded blood sugar level of 37. The resident, who had a diagnosis of diabetes mellitus and the capacity to make decisions, was admitted to the facility and had a low blood sugar event documented in the Medication Administration Record and SBAR form. While the physician was notified of the hypoglycemic event, there was no documentation in the medical record indicating what interventions, if any, were provided to address the low blood sugar. Interviews with nursing staff revealed that standard practice for blood sugar levels of 70 or below included providing orange juice or glucagon and notifying the physician. One LVN stated she gave orange juice and rechecked the blood sugar, but admitted she did not document these actions. The Director of Nursing confirmed that all interventions should be documented according to facility policy, which requires monitoring and documenting the resident's progress and response to treatment. The lack of documentation made it unclear what care was provided during the hypoglycemic episode.
Controlled Medication Accountability Issues
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the Medication Count Sheets and the Medication Administration Records (MAR). For Resident 247, two Norco 5/325 mg tablets were signed out but not documented as administered on the MAR. Similarly, Resident 1 had one tablet unaccounted for in April and four in May, while Resident 18 had 11 tablets unaccounted for in May and five in June. These discrepancies were acknowledged by the Registered Nurse Supervisor during the survey. The facility's process for controlled medication administration involves assessing the resident's pain, signing out the medication from the count sheet, and documenting the administration in the MAR. However, the documentation was missing for the dates and times specified for the three residents. The facility's policies require the individual administering the medication to record details such as the date, time, dosage, and their signature, which was not adhered to in these instances.
Failure to Follow Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Hydralazine Hydrochloride, a medication used to control high blood pressure, for a resident diagnosed with hypertension and Chronic Obstructive Pulmonary Disease (COPD). The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 130. However, from May 11, 2024, through June 3, 2024, the resident received the medication multiple times despite having systolic blood pressure readings below the prescribed threshold. During an interview and record review on June 3, 2024, a registered nurse acknowledged that the medication was administered contrary to the physician's parameters. The nurse admitted that the licensed nurses did not follow the specified guidelines and should have contacted the physician regarding the resident's blood pressure readings. The facility's policy on administering medications, dated April 2023, mandates that medications be administered in accordance with prescriber orders, which was not followed in this instance.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that dietary staff were able to carry out the functions of food and nutrition services safely and effectively. Dietary Aide 3 did not follow the facility's cleaning procedure for food preparation surfaces and stationary equipment, using only sanitizer without rinsing off detergent, which could lead to cross-contamination. Additionally, two kitchen staff members did not document the cooling process for boiled eggs and tuna salad, which is essential to prevent foodborne illness by ensuring food is cooled quickly to minimize bacterial growth. Furthermore, a staff member was not trained to calibrate thermometers, which is necessary to ensure accurate temperature readings for food safety. The Dietary Services Supervisor indicated that all cooks should know how to calibrate thermometers, but this was not the case. Additionally, there were issues with the use of sanitizer test strips and the immersion of kitchenware in sanitizer. One staff member did not follow the correct time for dipping test strips in sanitizer, and another did not follow the manufacturer's guidelines for immersing kitchenware in sanitizer, both of which could lead to ineffective sanitization. These failures had the potential to result in unsafe food practices, which could lead to foodborne illness and not meet the nutritional needs of the residents. The report highlights the lack of adherence to established procedures and training deficiencies among the dietary staff, which could compromise the safety and quality of food services provided to the residents.
Failure to Adhere to Prescribed Dietary Orders
Penalty
Summary
The facility failed to meet the nutritional needs of three residents by not adhering to the prescribed dietary orders. Resident 297, who was on a physician-prescribed Fortified diet, received diet Jello instead of regular Jello and only one package of dressing instead of two during lunch meals. This was confirmed through interviews with the Treatment Nurse and Dietary Services Supervisor, who acknowledged the discrepancies and the Registered Dietician who emphasized the importance of following the prescribed diet to ensure adequate calorie intake. Resident 25, on a Controlled Carbohydrate Diet, was served a regular portion of chocolate cake with frosting instead of a half portion without frosting. This error was observed during a lunch meal and confirmed by the Dietary Services Supervisor, who admitted the mistake. The Registered Dietician reiterated the necessity for kitchen staff to adhere to the Cook's Spreadsheet to ensure compliance with the dietary orders. Resident 26, who required large portion meals, was served a regular portion of pasta instead of the prescribed large portion. This was observed during a lunch meal and confirmed by the Dietary Services Supervisor. The Registered Dietician highlighted the importance of following the physician's orders and the facility's policy on portion sizes to meet the nutritional needs of the residents.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Food service workers did not adhere to the facility's cleaning procedures for food preparation surfaces. Specifically, staff members were seen using sanitizing solutions without properly cleaning and rinsing the surfaces first, which is against the facility's policy. This improper cleaning method was confirmed by the Registered Dietician, who emphasized the risk of cross-contamination if surfaces are not cleaned according to the established procedures. Additionally, the kitchen and storage areas were found to be in unsanitary conditions, with dust and debris present in multiple locations, including vents, walls, and equipment. The Dietary Services Supervisor confirmed the presence of dust and acknowledged that it should not be there, as it poses a risk of cross-contamination. The facility's policies require regular cleaning of these areas, but observations indicated that these procedures were not being followed, leading to unsanitary conditions. The facility also failed to ensure the quality and proper storage of food items. Poor quality produce was found in the walk-in refrigerator, and several kitchen appliances and utensils, such as the can opener and blender, had visible buildup. Open food items were left exposed in the freezer, and a container of margarine was not labeled or dated. These practices are contrary to the facility's policies, which require proper labeling, dating, and storage of food items to prevent spoilage and maintain food safety.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. For Resident 147, who had a urinary catheter, there was no Enhanced Barrier Precaution (EBP) sign posted in the room, nor was there a container for disposing of used cloth gowns and linens. Interviews with the Restorative Nursing Assistant and nursing staff revealed that they were aware of the need for EBP but failed to implement it. The Director of Staff Development/Infection Preventionist confirmed that residents with urinary catheters should be on EBP, and necessary signs and containers should be present in the room. Nursing staff also failed to properly clean and disinfect shared medical equipment. An automatic blood pressure cuff machine was not disinfected after use on Resident 101, contrary to the facility's policy and CDC guidelines. Similarly, prefilled insulin pens for Residents 27 and 37 were not wiped with alcohol before use, as required by the manufacturer's instructions. Interviews with the nursing staff and the Director of Staff Development/Infection Preventionist confirmed these lapses in following proper procedures. Additionally, the facility did not ensure the correct disinfection of shared glucometers. The glucometer used for Residents 18, 25, 27, 32, and 97 was cleaned with inappropriate wipes, which were not effective against bloodborne pathogens. The Infection Preventionist and nursing staff acknowledged the error and confirmed that the correct wipes were not used. The facility's policy and the manufacturer's instructions were not followed, leading to potential cross-contamination risks.
Kitchen Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a clean and safe operating condition, as observed during a survey. The reach-in freezer had significant ice buildup at the top and ice drips forming under the top shelf, indicating it was not functioning properly. This was confirmed by both the Dietary Services Supervisor (DSS) and the Administrator. Additionally, three storage shelves within the freezer had cracked coatings, which the DSS and Registered Dietician (RD) acknowledged could lead to physical contamination of food due to bacterial growth in the cracks. Further observations revealed that the bottom shelf of a food preparation table was corroded, with rust, dust, and food particles present. The DSS and RD both noted that rust in the kitchen poses a risk of cross-contamination. In the dry storage room, two storage racks for dry foods were found with rust, which the DSS identified as inappropriate for kitchen use due to contamination risks. The RD reiterated the expectation for kitchen equipment to be free of rust. Additional deficiencies included a blue cutting board with a rough surface and deep cutting marks, which the DSS and RD agreed needed replacement to prevent bacterial growth. A dome drying rack was also found with cracked plastic coating and exposed rusting metal, which the DSS and RD stated could cause cross-contamination. The facility's policies on sanitation and maintenance were reviewed, indicating that all equipment should be kept clean, in good repair, and free from corrosion, breaks, and cracks.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the presence of a gnat in the dry storage room and four house flies in the kitchen. On June 3, 2024, a gnat was observed flying around a plastic bin containing four brown bananas in the kitchen's dry storage room. The Dietary Services Supervisor acknowledged that ripe bananas attract gnats and emphasized the importance of keeping pests out to prevent cross-contamination of food. On June 4, 2024, four flies were seen flying and landing in various areas of the kitchen. An interview with a staff member revealed that flies enter the kitchen whenever the door is opened, and the ceiling fan is not effective in keeping them out. The Registered Dietician confirmed that flies should not be present in the kitchen due to the risk of cross-contamination. The facility's pest control policy, dated August 2022, states that the facility maintains an ongoing pest control program to keep the building free of insects and rodents.
Failure to Provide Dignity Bag for Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 297, was treated with respect and dignity by not providing a dignity bag to cover the resident's indwelling urinary catheter drainage bag. This oversight was observed during a survey when the drainage bag was visibly hanging at the foot of the resident's bed without a dignity bag. The resident, who was admitted with diagnoses including cerebral palsy, chronic obstructive pulmonary disease, and hemiplegia, had a severe cognitive impairment as indicated by a BIMS score of 2. During an observation and interview, a Certified Nurse Assistant acknowledged the absence of a dignity bag and stated that the lack of coverage could cause embarrassment to the resident. The Director of Staff Development/Infection Preventionist confirmed that all nursing staff are responsible for maintaining residents' dignity by ensuring the use of dignity bags to cover urinary catheter drainage bags. The facility's policy on Resident Rights emphasizes the importance of treating residents with respect, kindness, and dignity, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 30, by not ensuring the call light button was within reach. During an observation and interview, it was noted that the call light button was secured to the wall at the head of the bed, making it inaccessible to the resident. Resident 30, who is in a wheelchair, confirmed that he could not reach the call light, and attempting to do so could result in a fall. This was corroborated by a Certified Nurse Assistant (CNA) who acknowledged the call light should be within reach and that the facility's practice is to ensure accessibility for all residents. The Director of Staff Development/Infection Preventionist (DSD/IP) also confirmed that the call light should be within reach for all residents, highlighting the risk of residents being unable to call for assistance if needed. Resident 30's medical history includes hemiplegia, a history of falling, and diabetes, which further emphasizes the importance of having the call light accessible. The facility's policy, revised in March 2023, mandates that the call light be within easy reach when residents are in bed or confined to a chair, which was not adhered to in this instance.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's family member of a significant change in the resident's condition and subsequent transfer to an acute hospital. The resident, who had been admitted with diagnoses including malignant neoplasm of the prostate and severe protein-calorie malnutrition, experienced a decline in condition requiring increased oxygen support and was transferred to the hospital. Despite the change in condition and transfer, the family member was not informed, leading to the family member searching for the resident two days later. The deficiency was identified during a review of the resident's records and interviews with facility staff. The records indicated that the family member's contact information was not available in the facility's system, and the nurse on duty did not notify the family member of the transfer. The facility's policy requires notification of a resident's representative in the event of a significant change in condition or transfer, which was not followed in this case.
Failure to Update Care Plan Post-Hospital Readmission
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was transferred to the hospital for chest pain. Upon the resident's return to the facility, the care plan was not updated with specific measurable goals and interventions for managing the resident's chest pain. This oversight was identified during a review of the resident's records, which showed that the care plan had not been revised following the resident's readmission after a hospital stay for a congestive heart failure exacerbation. The resident, who has a medical history including congestive heart failure, myocardial infarction, and a cardiac pacemaker, was observed to be without discomfort during a survey. However, the Registered Nurse Supervisor confirmed that the care plan should have been updated upon the resident's readmission. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition or when a resident is readmitted from a hospital stay, which was not adhered to in this case.
Failure to Document Pacemaker Information for Residents
Penalty
Summary
The facility failed to obtain and document pacemaker information for two residents, leading to a deficiency in their care plans. Resident 8, who was admitted with diagnoses including congestive heart failure and a cardiac pacemaker, had no documented evidence of pacemaker information in her medical record upon initial admission and readmission. Despite a history of severe chest pain and hospitalization, the care plan lacked details about the pacemaker, such as its type, leads, and monitoring requirements. The Registered Nurse Supervisor confirmed the absence of this critical information, which was necessary for regular monitoring and evaluation by a cardiologist. Similarly, Resident 97, admitted with cellulitis and a pacemaker, also lacked documented pacemaker and AICD information in his medical record. Despite a hospital transfer due to low hemoglobin and subsequent readmission, the care plan did not include essential pacemaker details. The Registered Nurse Supervisor acknowledged that the information should have been obtained and documented upon admission and readmission. The facility's policy required comprehensive documentation of pacemaker details, which was not adhered to in these cases.
Oxygen Administration Without Physician's Order
Penalty
Summary
The facility failed to provide respiratory care and treatment in accordance with its policy and procedure for a resident who was administered oxygen without a physician's order. This deficiency was identified during observations and interviews conducted over several days. On June 3, 2024, a resident was observed using oxygen at two liters per nasal cannula attached to an oxygen concentrator. The following day, the same resident was seen using oxygen from a portable tank while in a wheelchair, and she confirmed using oxygen continuously since her admission to the facility. Further investigation revealed that the resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and congestive heart failure, did not have a documented physician's order for oxygen administration. Interviews with facility staff, including a CNA, an LVN, and the Registered Nurse Supervisor, confirmed the absence of such an order. The facility's policy, revised in March 2023, clearly stated the requirement for a physician's order for oxygen administration, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 13.89% during a medication administration observation, where five errors occurred out of 36 opportunities. This involved two residents, where medications were not administered according to physician's orders. For one resident, the Licensed Vocational Nurse (LVN) misread the blood pressure and heart rate parameters, resulting in the failure to administer prescribed blood pressure medications, carvedilol and losartan/hydrochlorothiazide, despite the parameters being met. The LVN acknowledged the error upon review of the physician's orders and confirmed that the medications should have been given. In another instance, the same LVN administered an incorrect dosage of escitalopram to a different resident, giving 10 mg instead of the prescribed 5 mg. Additionally, the LVN failed to administer ferrous sulfate and a lidocaine patch as ordered. The LVN admitted to missing these medications during the administration process. The Registered Nursing Supervisor confirmed that the medications should have been administered as per the physician's orders unless the resident refused, and acknowledged that the discontinued escitalopram should not have been given. The facility's policy requires medications to be administered safely, timely, and as prescribed.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required bedroom space of at least 80 square feet per resident in 12 resident rooms, specifically Rooms 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34. During an entrance conference, the Administrator acknowledged that these rooms did not meet the space requirement and mentioned that the facility had a waiver for the rooms and would be requesting a renewal. Observations and interviews conducted during the survey dates revealed that there were no adverse effects on the quality of life of the residents residing in these rooms. Resident 24, when interviewed, stated that the room size did not interfere with his care and there was enough space for him to move about in the room. The Administrator submitted the necessary requirements for the continuation of the room waivers for the mentioned rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Care And Rehabilitation Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Woodcrest Post Acute & Rehabilitation | 1.6 mi | ★★★★★ | 15 | 0 |
| Extended Care Hospital Of Riverside | 1.6 mi | ★★★★★ | 17 | 0 |
| Community Care On Palm | 1.8 mi | ★★★★★ | 15 | 0 |
| Riverside Behavioral Healthcare Center | 2 mi | ★★★★★ | 15 | 0 |
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