Health inspection·May 30, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of physical abuse involving two residents (Resident 1 and Resident 2) to the State Survey Agency, immediately or or not later that two hours after the allegation was made. This failure had the potential to result in a delay to protect the residents from further abuse. Findings: On April 4, 2023, at 12:16 p.m., at 12:16 p.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's medical record indicated she was admitted on [DATE], with diagnoses of stroke, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), schizoaffective disorder (a chronic mental health condition that involves symptoms of disturbances in thought and mood swings), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Resident 1's History and Physical, dated March 10, 2023; indicated she did not have the capacity to understand and make decisions. A review of Resident 1's document titled, SBAR (situation, background, assessment, recommendation) Communication Form, dated March 30, 2023, at 3:14 p.m., indicated .PER REPORT BY CARE STAFF RESIDENT GRABBED AND PULLED THE HAIR OF ANOTHER RESIDENT IN THE HALLWAY . A review of Resident 2's medical record indicated she was admitted to the facility on [DATE]; with diagnoses of COVID-19 (highly contagious respiratory disease caused by the SARS-CoV-2 virus), and pathological fracture (a broken bone caused by disease, often by the spread of cancer to the bone). A review of Resident 2's SBAR Communication Form, dated March 30, 2023, at 3 p.m., indicated .Got her hair pulled and got scratches by another resident (Resident 1) . On April 4, 2023, at 1:53 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that on March 30, 2023, Resident 1 grabbed Resident 2 by the hair. On April 4, 2023, at 3:08 p.m., an interview was conducted with the facility Administrator (ADM). (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: 555331 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 555331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valencia Gardens Health Care Center 4301 Caroline Court Riverside, CA 92506 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)