Health inspection·April 18, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many this is a safety issue and could cause an injury. The DON pushed the plastic pipes with his foot and moved them, and the water was dripping into the drain and not onto the floor. The DON stated the pipes should be secured in place, to ensure the water was draining properly. On April 18, 2025, at 10:50 a.m., an interview was conducted with the DS. The DS stated she did not know how often the water filters are being changed, they were not dated, the maintenance department usually takes care of that, and the ice machine had been serviced this year. The DS stated she will have to check with maintenance when the water filters were last changed. On April 18, 2025, at 12:50 p.m., an interview was conducted with the maintenance supervisor (MS). The MS stated the kitchen staff clean the ice machine every month and the ice machine was serviced by an outside company twice a year. The MS stated the outside company cleans the machine, replaces parts, and if needed will come out in between for maintenance. The MS stated it was serviced in January 2025 and there were no issues with the ice machine at that time. The MS stated the water filter for the ice machine were being changed every six (6) months per manufacturer's recommendations, he changes out the water filters himself, he does not date the filters, the filters have a button on them, to push and it will tell you how long it has been in use, he forgot to push the button on the current filter being used at [NAME] a monthly basis, a pest control company will inspect and service the Food & (and) Nutrition Services Department .is time. The MS stated the kitchen staff should be wiping down the ice machine and the areas around it daily. On April 18, 2025, at 4:50 p.m., an interview was conducted with the DON. The DON stated he inspected the ice machine, and the black/brown flecks are from the rubber aligning the ice dispenser, it is cracking and breaking down. The DON stated he would not want any rubber particles in his ice, it will need to be replaced, and it could affect the residents. A review of the facility's policy and procedure titled Ice Machine Cleaning Procedures, dated 2023, indicated, the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations .The maintenance supervisor can keep this record or .on the ice machine .be sure special attention is paid to cleaning the door molding . A review of the Manufacturer's Recommendations for the Ice Pro 800, water treatment system, indicated, .cartridge change out monitor label. Press the bubble firmly on the 'service filter' label to activate the 6 month timer .cartridge should be replaced every 6 months or when scale begins to form in the treated equipment . A review of the facility's policy and procedure titled Sanitation, dated 2023, indicated, .all equipment shall be maintained as necessary and kept in working order .each employee shall know how to operate and clean all equipment in his specific work area .the FNS (Food and Nutrition Services) director will write the cleaning schedule .on a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department .all .equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .Ice which is used in connection with food and drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner .the kitchen staff is responsible for all cleaning . A review of the facility's document titled Pest Control, dated 2010, indicated, .common kitchen pests .cockroaches .carry and transmit disease, including salmonella, dysentery and diarrhea .ants .transport filth and waste .often enter facilities in search of water .deprive pests of food, water and shelter by following good cleaning procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055255 If continuation sheet Page 2 of 6 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 055255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Health Care Center 1400 Circle City Drive Corona, CA 92879 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 Based on observation, interview, and record review, the facility failed to ensure devices used for the residents, were sanitary, clean, and disinfected properly, when: Residents Affected - Some 1. The pill crusher was observed with brown sticky substance, for 15 of 27 residents which required medications to be crushed; and 2. The stand lift machine (a non-electric standing aid designed to assist seniors in safely rising from a seated position in chairs, couches, or recliners) was observed to be dirty, for one of one resident who uses the stand lift machine. These failures had the potential to result in the residents being exposed to unsanitary shared devices which could lead to spread of infections. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:10 a.m., an observation of Nurse Station 3 (three) and hallway 300 was conducted. The Medication Cart 3 (three) was noted to have a pill crusher on top of the cart and was coated in a brown, semi soft, sticky substance, covering the area the pills were being placed inside to crush. The EZ-Up (brand of stand lift machine) transfer lifting equipment was observed to have crumbs, as well as white and beige colored flakes on the bottom of the device, where the resident's feet were being placed to stand up. On April 18, 2025, at 11:30 a.m., an observation and concurrent interview was conducted with the Licensed Vocational Nurse (LVN). The LVN looked at the EZ-Up transfer lifting equipment, the white flakes on the bottom portion where the resident's feet are to be supported looked like food crumbs, as well as feet flakes (flaky skin from the feet sheds off due to dry skin, fungal infections, and skin conditions). The LVN stated the EZ-UP were to be cleanse by the maintenance department. The LVN stated she would not want to be standing on the piece of equipment barefoot, it looked dirty, it needed to be cleaned. The LVN looked at the pill crusher and stated it might be apple sauce on the pill crusher, not sure, but has not been wiped down, it should be cleaned, and it needed to be cleaned before using the item. The LVN stated whatever the brown stuff was on the pill crusher could get on your hands or gloves, it's gross, it should not be used for the residents for infection control reasons. On April 18, 2025, at 11:40 a.m., an observation and concurrent interview was conducted with the Administrator (Admin). The Admin walked over to station 3 (three), observed the EZ-Up transfer lifting equipment and the pill crusher. The Admin stated the pill crusher should be cleaned down by the nurses, and the EZ-Up transfer equipment should be cleaned by housekeeping. The Admin stated we should know who would be responsible in cleaning the equipment between uses, and it should not be left sitting in the hallway without being cleaned. A review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces, dated August 2019, indicated, .Environmental surfaces will be cleaned and disinfected according to current CDC (Centers Disease Control and Prevention) recommendations for disinfection .levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055255 If continuation sheet Page 3 of 6 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 055255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Health Care Center 1400 Circle City Drive Corona, CA 92879 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete .non-critical environmental surfaces .decontaminate where they are used .will be disinfected with an .intermediate or low-level hospital disinfectant .spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated . A review of the facility's policy titled Infection Prevention and Control Program, dated October 2018, indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .the program is based on accepted national infection prevention and control standards .is a facility-wide effort involving all disciplines and individuals . Event ID: Facility ID: 055255 If continuation sheet Page 4 of 6 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 055255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Health Care Center 1400 Circle City Drive Corona, CA 92879 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and functional environment, for two of two residents who independently uses the smoking patio (Resident A and Resident B), when the fire door closed was dismantled. In addition, the ceiling above the fire door closer was observed to have water damage. These failures had the potential to cause injury to Residents A and B while entering or exiting through the fire door. In addition, the stained ceiling had the potential for it to collapse and could injure residents and staff. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:50 a.m., an observation and concurrent interview was conducted with Resident A. Resident A was observed to wheel himself to the smoking area. Resident A was observed to go outside through the exit door, at the end of hallway 100. The fire door closer was observed to be dismantled, and the door did not close properly. Resident A was observed to push on the bar inside of the door with his left hand, at the same time lifted up on the outside door handle with his right hand while pulling up the door to close it, and moved his left hand out of the door before it closed on his fingers. In a concurrent interview with Resident A, he stated they do this all the time and they have not got their hands caught yet. On April 18, 2025, at 12:50 p.m., an observation and concurrent interview was conducted with the Maintenance Supervisor (MS). The MS observed the fire door at the back of hallway 100, the door closer hinge was noted to be dismantled. The MS stated he dismantled the closer to keep the door from slamming shut on any of the residents going outside to smoke on the patio. The MS demonstrated by opening the fire door and as the door closed, it would catch on the concrete and not close completely. The MS stated he need to reattach the mechanism to have the fire door close properly again, it is not safe, if there is a fire and it does not close correctly it can potentially harm the residents. The ceiling tile above the fire door exit sign was observed to have dark brown stain, was splitting, and deteriorating. The MS stated he had not noticed the ceiling tile looking like that. The MS stated there might have a leak as there was plumbing above the ceiling. The MS stated one of the pipes might need repair and the ceiling tile needed to be changed to prevent from it breaking and could fall on one of the residents, it is not safe. On April 18, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included paraplegia (a type of paralysis that affects the lower half of the body, resulting in the inability to move the feet, legs, and sometimes to abdomen), and Diabetes Mellitus (high levels of sugar in the blood). A review of Resident A's care plan, dated June 8, 2023, indicated, .Resident A is alert and oriented, he may go outside to the patio to smoke . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055255 If continuation sheet Page 5 of 6 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 055255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Health Care Center 1400 Circle City Drive Corona, CA 92879 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 0921 Level of Harm - Minimal harm or potential for actual harm On April 18, 2025, at 3:20 p.m., an observation and concurrent interview was conducted with Resident B. Resident B was observed out on the smoking patio, he went to close the fire door by pushing the inside bar with his left hand, while lifting up on the outside door handle, and pushing the door closed, and almost getting his fingers pinched in the door. Resident B stated it was the only way to close it as it would not close on its own. Residents Affected - Some On April 18, 2025, a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE], with diagnoses which included cirrhosis of the liver (liver damage from different causes leading to scarring and liver failure) and ascites (excess abdominal fluid, swelling caused by an accumulation of fluid, related to liver disease). A review of Resident B's care plan, dated October 2, 2024, indicated, .A smoker with potential for smoking-related injuries, interventions included: resident may smoke with supervision, will use protective clothing (smoking apron) for safety . A review of the facility's policy titled Smoking Policy Residents, dated October 2023, indicated, .This facility has established and maintains safe resident and smoking practices .ability to smoke safely with or without supervision .Any smoking-related privileges, restrictions, and concerns .are noted on the care plan . A review of the facility's policy titled Fire and Smoke Barrier Doors, dated 2023, indicated, .Fire and smoke barrier doors are strategically located throughout the facility and such doors remain operable at all times .This facility has automatic fire and smoke barrier doors to contain fire and smoke .Fire and smoke barrier doors are not to be .held open by any means other than the automatic holding device built into the door .Staff are to report fire and smoke doors that are partially open or do not close properly .to the maintenance supervisor. Staff shall also notify the safety coordinator . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055255 If continuation sheet Page 6 of 6