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). Page 1 of 2 555331 555331 05/30/2023 Valencia Gardens Health Care Center 4301 Caroline Court Riverside, CA 92506

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADM stated the incident between Resident 1 and Resident 2 occurred on March 30, 2023, at approximately 3 p.m. The ADM stated that on March 30, 2023, at 3:54 p.m., he sent instruction to the Social Service Director (SSD) via text, to fax the Facility Reported Incident (FRI) report involving Residents 1 and 2 to CDPH (California Department of Public Health) Licensing and Certification. The ADM, during the interview, reviewed his text message and stated that the message he sent to the SSD did not go through. He stated the report had not been faxed. A review of the report on the incident of alleged physical abuse involving Residents 1 and 2, indicated the report was received by the State Survey Agency on April 4, 2023 ( 5 days after the incident occurred). A review of the facility's policy and procedure titled Elder/Dependent Adult Abuse revised December 17, 2019, indicated .Jurisdiction in long-term care facilities .Phone/fax All alleged violations—Immediately but not later than 2 hours—involves any type of alleged abuse .c. If reportable, document a written abuse report on a SOC 341 (from the State Department of Social Services). Report of suspected Dependent adult/elder abuse and submit to d. the appropriate agencies . 555331 Page 2 of 2