Health inspection·December 4, 2024

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 4 ' s AR, the AR indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia and unspecified psychosis (severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality). During a review of Resident 6 ' s AR, the AR indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body). During a review of Resident 7 ' s AR, the AR indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and unspecified heart failure (disorder characterized by the inability of the heart to pump blood at an adequate volume for organ function). During a review of Resident 2 ' s AR, the AR indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) protein-calorie malnutrition. During a review of the decision by the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) and the Department of Consumer Affairs (DCA) for the State of California, dated [DATE], the decision indicated the OA surrendered OA ' s LVN license effective [DATE]. The decision indicted the OA signed the decision on [DATE]. The decision indicated the OA ' s LVN license expired on [DATE]. During a review of Resident 8 ' s electronic medication administration record (eMAR- record that documents the administration of medication into a resident ' s electronic health record) dated 10/20023, the eMAR indicated the OA indicated on [DATE], [DATE], [DATE], and [DATE], the OA monitored Resident 8 for decreased interest with daily activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself) leading to self-isolation every shift with use of Lexapro (antidepressant medication) during the day shift and night shift for a total of eight entries. During a review of the same eMAR, the eMAR indicated on [DATE], [DATE], and [DATE], the OA monitored Resident 8 for sudden fluctuations of mood, sudden anger, and irritability every shift with use of Depakote (psychotropic- drugs/medications that affect a person ' s mental state) during the day shift and night shift, and on [DATE] during the night shift for a total of seven entries. During a review of the same eMAR, the eMAR indicated on [DATE], [DATE], [DATE], and [DATE] the OA monitored Resident 8 for persistent delusion for combat and ready to fight causing verbal aggression, every shift with use of Zyprexa (psychotropic medication) during the day shift and night shift for a total of eight entries. During a review of Resident 8 ' s eMAR dated 11/2023, the eMAR indicated on [DATE], [DATE], and [DATE], the OA monitored Resident 8 for sudden fluctuations of mood, sudden anger, and irritability every shift with use of Depakote, during the day shift for a total of three entries. During a review of the same eMAR, the eMAR indicated on [DATE], [DATE], [DATE], and [DATE], the OA monitored Resident 8 for persistent delusion for combat and ready to fight causing verbal aggression, every shift with use of Zyprexa, during the day shift for a total of four entries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 2 of 7 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 9 ' s eMAR dated 11/2023, the eMAR indicated on [DATE] at 12:15 pm, the OA signed that Resident 9 ' s diet was provided as Resident 9 ' s physician ordered with meals. During a review of Resident 3 ' s eMAR dated 11/2023, the eMAR indicated on [DATE] at 2 pm, the OA gave Resident 3 four ounces (oz- unit of measurement) of high protein nutrition (HPN) for supplement for six months (between meals). During a review of Resident 3 ' s eMAR dated 12/2023, the eMAR indicated on [DATE] at 2 pm, OA gave Resident 3 four oz of HPN for supplement for six months (between meals). During a review of Resident 4 ' s eMAR dated 12/2023, the eMAR indicated on [DATE] the OA monitored Resident 4 for delusions that someone was trying to imprison Resident 4 in the facility, every shift with use of Risperidone (psychotropic medication), during the day shift. During a review of Resident 5 ' s AR, the AR indicated Resident 5 was initially admitted to the facility on [DATE] and again on [DATE] with diagnoses that included dementia and unspecified mood disorder (described by marked disruptions in emotions with severe lows and highs). During a review of Resident 5 ' s eMAR dated 3/2024, the eMAR indicated on [DATE] and [DATE], the OA monitored Resident 5 for persistent delusions that people are secretly planning to do something against Resident 5 causing Resident 5 to falsely accuse everyone, every shift with use of Quetiapine (psychotropic medication), during the day shift for a total of two entries. During a review of Resident 6 ' s electronic treatment administration record (eTAR- a software system that electronically documents and tracks the administration of medical treatments to patients) dated 3/2024, the eTAR indicated on [DATE], the OA monitored Resident 6 ' s skin integrity to the right hand daily, every day-shift. During a review of Resident 2 ' s eMAR dated 3/2023, the eMAR indicated on [DATE] at 9 am, the OA administered Calcium (mineral supplement) 600 mg oral tablet, one tablet by mouth one time a day for supplement. During a review of Resident 1 ' s eMAR dated 3/2024, the eMAR indicated on [DATE] at 9 am, the OA administered Docusate Sodium (stool softener) tablet, 100 milligrams (mg- unit of measurement), one tablet by mouth two times a day for stool softener. During a review of Resident 7 ' s eTAR dated 3/2024, the eTAR indicated on [DATE] the OA monitored Resident 7 for discoloration to the left, lower forearm for the follow adverse changes; hematoma (bruise) formation, during the day shift. During a review of the facility ' s in-service titled, Human Resources Issues, dated [DATE], the in-service indicated the OA was no longer the DSD. During a review of the JD titled, Medical Records Supervisor/Coordinator, dated [DATE], the JD indicated on [DATE], the OA signed the JD, indicating the OA was the Medical Records Supervisor/Coordinator. During a review of the JD titled, Office Assistant, dated [DATE], the JD indicated on [DATE], the OA signed the JD, indicating the OA was the office assistant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 3 of 7 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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 0839 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5 ' s Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 5 had severely impaired cognition (ability to think, remember, and reason). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. Residents Affected - Some During a review of Resident 8 ' s MDS dated [DATE], the MDS indicated Resident 8 moderately impaired cognition. During a review of Resident 9 ' s MDS dated [DATE], the MDS indicated Resident 9 had moderately impaired cognition. During a review of Resident 1 ' s MDS dated [DATE], the MDS indicated Resident 1 had severely impaired cognition. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 moderately impaired cognition. During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 had moderately impaired cognition. During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 had severely impaired cognition. During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 had moderately impaired cognition. During a concurrent interview and record review on [DATE] at 3:30 pm, with the Payroll and Admissions Coordinator (PAC), the OA ' s Punch Detail Report (PDR) was reviewed. The PAC stated the OA worked in tangent with the (new) DSD but did not know what the OA ' s title was. During an interview on [DATE] at 4:05 pm, with the OA, the OA stated the OA used to be a LVN, but no longer worked in a LVN capacity because the OA, lost his license. During an interview on [DATE] at 4:38 pm, with the ADM, the ADM stated the OA was working in the facility as the DSD but the OA ' s license was revoked and had been working as an office assistant since 4/2024. The ADM stated the OA was being investigated by the BVNPT for working as a DSD when the OA did not have a license to do so. During an interview on [DATE] at 11 am, with the ADM, the ADM stated that the OA was working as the facility ' s DSD from at least 10/2023 until [DATE]. The ADM stated the ADM found out the OA ' s license expired on [DATE] when the ADM received a call from BVNPT on [DATE], and the ADM pulled the OA from the DSD role. The ADM stated when the ADM asked the OA why the OA was working with an expired license, the OA, Provided excuses, before sharing the OA surrendered his license on [DATE]. The ADM stated the ADM looked up the OA ' s license and learned it was surrendered on [DATE]. The ADM stated part of the DSD ' s JD was to be in charge of ensuring everyone ' s licenses (for licensed nurses) and certifications (for certified nurse assistants [CNA]) were current and the OA did not disclose to the ADM his license had been surrendered. The ADM stated as the DSD between [DATE] to [DATE], the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 4 of 7 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some OA could have been providing direct patient care to residents because as the DSD, the OA would cover for licensed nurses when needed and provided direct patient care training or training to new licensed nurses. During a concurrent interview and record review on [DATE] at 12:28 pm, with the ADM, an audit of the eMAR and eTAR between 10/2023 and 4/2024 were reviewed. The ADM stated the OA had signatures in the eMAR and eTAR on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicating the OA was either administering medications and monitoring residents or training staff on how to administer medications and monitor residents. The ADM stated the signatures in the eMAR and eTAR indicated the OA was providing direct patient care without a license to do so. During an interview on [DATE] at 12:56 pm, with the DON, the DON stated the DSD, DON, and ADM get an alert in the facility ' s application for scheduling shifts when a licensed nurse or CNAs license or certification is due to expire. The DON stated the DON did not get a notification in 12/2023 that the OA ' s license was due to expire on [DATE]. The DON stated the OA informed the DON and ADM in 4/2024 (can ' t recall exact date) that the OA ' s license was surrendered and that ' s why the OA could not renew his license after [DATE]. During a concurrent interview and record review on [DATE] at 1:16 pm, with the OA, the OA ' s BVNPT and the DCA for the state of California, dated [DATE] was reviewed. The OA stated the OA did not understand that by signing the decision on [DATE], the OA was effectively surrendering his license on [DATE]. The OA stated the OA ' s lawyer explained the decision and provided a copy of it to the OA, but that the lawyer Explained everything really fast. The OA stated the first page of the decision indicated OA ' s license was effectively surrendered on [DATE]. The OA stated the OA did not tell the ADM or DON the OA ' s license was surrendered and then expired. The OA stated in order to train new staff, the trainer must have their nursing license. The OA stated the OA must have a nursing license to administer medication and monitor residents. The OA stated it was possible if the OA signed his initials in the eMAR or eTAR between 10/2023 and 4/2024, the OA was providing direct patient care in the form of administering medications and monitoring residents with the staff the OA was training. The OA stated the risk of providing patient care without a license was that the OA could put the residents ' lives at risk. During a concurrent interview and record review on [DATE] at 4:30 pm, with the DON, Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9 ' s eMAR and eTAR ' s were reviewed. The DON stated if the OA ' s initials were signed in Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9 ' s eMAR and eTAR ' s, it indicated the OA administered medications and/or provided monitoring to the residents. The DON stated on [DATE], [DATE], [DATE], and [DATE], the OA monitored Resident 8 for behavior of decreased interest with ADL ' s. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE], [DATE], [DATE], and [DATE] the OA monitored Resident 8 for the behavior of sudden fluctuation of mood. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE], [DATE], [DATE], and [DATE] the OA monitored Resident 8 ' s persistent delusion for combat ready to fight causing verbal aggression. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE], [DATE], and [DATE] the OA monitored Resident 8 for the behavior of sudden fluctuation of mood. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE], [DATE], [DATE], and [DATE] the OA monitored Resident 8 ' s persistent delusion for combat ready to fight causing verbal aggression. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE] at 12:15 pm the OA monitored Resident 9 that the daily diet was provided as ordered. The DON stated by signing the eMAR, it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 5 of 7 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated the OA did the monitoring. The DON stated on [DATE] at 2 pm, the OA provided four oz of high protein nourishment to Resident 3. The DON stated by signing the eMAR, it indicated the OA provided the nourishment. The DON stated on [DATE] at 2 pm, the OA provided four oz of high protein nourishment to Resident 3. The DON stated by signing the eMAR, it indicated the OA provided the nourishment. The DON stated on [DATE], for the day shift, the OA monitored Resident 4 for behavior of delusions that someone was trying to imprison Resident 4. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE] and[DATE] day shift, the OA monitored Resident 5 for persistent delusions that people were secretly planning to do something against Resident 5 causing Resident 5 to falsely accuse everyone. The DON stated by signing the eMAR, it indicated the OA did the monitoring. The DON stated on [DATE] day shift, the OA monitored Resident 6 for skin integrity to the right hand. The DON stated by signing the eTAR, it indicated the OA did the monitoring. The DON stated on [DATE] at 9 am, the OA administered Calcium 600 mg, one tablet, to Resident 2. The DON stated by signing the eMAR, it indicates the OA administered the medication. The DON stated on [DATE] at 9 am, the OA administered docusate sodium, one tablet to Resident 1. The DON stated by signing the eMAR, it indicated the OA administered the medication. The DON stated on [DATE] day shift, the OA monitored Resident 7 for discoloration to the left forearm. The DON stated by signing the eTAR, it indicated the OA did the monitoring. The DON stated the above monitoring and medication administration could not be performed by staff who did were not licensed nurses. The DON stated if a staff member did not have a license to practice nursing, they could not administer medications or monitor residents because it was a liability issue. The DON stated it was a safety issue for all residents. During a review of the facility ' s P&P titled, Licensure, Certification, and Registration of Personnel, revised 4/2007, the P&P indicated employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment. The P&P indicated a copy of the current license, certification, or registration number must be filed in the employee ' s personnel record. The P&P indicated a copy of recertifications must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. The P&P addendum dated [DATE] indicated the DSD was in charge of verifying licenses, certifications/registrations of staff. The P&P addendum indicated the DSD was responsible for reflecting updated licenses or certifications of staff in the on-shift program of the facility. The P&P addendum indicated the on-shift program did not allow licensed nurses to be scheduled for licenses that were expired. The P&P indicated addendum indicated any inconsistencies or expirations should be reported to the ADM by the DSD for prompt action like discharging staff from such positions. During a review of the JD titled, DSD, dated [DATE], the JD indicated essential duties and responsibilities included making regular checks for competency of CNA skills performances, positive regard for residents, and developmental needs of direct care staff, and conducted mini-in-service immediately, if necessary, and provided resources for licensed staff in-services in clinical skills development. The JD indicated other duties included to perform daily rounds in the facility to assess and identify resident problem/needs, and conducts staff in-services when needed, to abate known problems, monitor weekly body checks process by treatment nurses to ensure timely performance and monitor daily body check process by CNAs, participate in plans of correction after the DON and QA surveys, and perform other duties or functions as assigned by the DON and/or administrator. The JD indicated education and/or work experience included to be a RN or LVN from an accredited school and minimum one year of nursing experience in a long-term care facility. The JD indicated the DSD have a current, verifiable license as a RN or LVN in the State of California (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 6 of 7 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 055126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766 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 0839 and must remain in good standing with the licensing board. The JD indicated the nursing license must be maintained in a current status and provide evidence of renewal as required by the facility ' s P&P. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055126 If continuation sheet Page 7 of 7