Other·March 10, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one entity reported incident. Entity reported incident number: CA00481928. Representing the California Department of Public Health: Surveyor 32192, HFEN. The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for entity reported incident number: CA00481928.

F492 SS=D COMPLY WITH FEDERAL/STATE/LOCAL LAWS/PROF STD CFR(s): 483.75(b)

F492 03/14/2017 The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an outbreak at the facility involving one resident, Resident 1, to the California Department of Public Health (CDPH) within the mandated 24 hour period of time. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 92QW11 Facility ID: CA240000045 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055255 (X3) DATE SURVEY COMPLETED 02/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CORONA HEALTH CARE CENTER 1400 Circle City Dr Corona, CA 92879 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility first learned about the infection on March 7, 2016, and reported it to CDPH on March 28, 2016, 21 days later. Findings: The California Code of Regulations (CCR), Title 22, Division 5, 72541, specifies, "Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require." Resident 1 was admitted to the GACH on March 4, 2016, with complaints of respiratory failure (difficulty breathing). On March 5, 2016, at 5:28 p.m., Resident 1 was diagnosed with a legionella infection (LD, according to the Centers for Disease Control, LD is a potentially serious lung disease caused by the bacteria Legionella that lives in water systems and is spread by breathing in water droplets). Resident 1 was admitted to a general acute care facility (GACH) where this diagnosis was confirmed. Resident 1 expired on March 8, 2016, while admitted to the GACH. The GACH notified the facility on March 7, 2016, at 2 p.m., about Resident 1's diagnosis of legionella infection. The facility notified the California Department of Public Health (CDPH) on March 28, 2016, 21 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 92QW11 Facility ID: CA240000045 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055255 (X3) DATE SURVEY COMPLETED 02/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CORONA HEALTH CARE CENTER 1400 Circle City Dr Corona, CA 92879 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE days after the facility was notified that the resident was initially diagnosed with a legionella infection. On March 29, 2016, at 8 a.m., an unannounced visit was made to the facility to investigate an entity reported incident that the facility had a case of legionella infection, with a possibility of an outbreak at the facility. On March 29, 2016, at 8:29 a.m., the Director of Staff Development (DSD), also the facility infection control designee, was interviewed. The DSD provided written documentation from the Administrator (ADM) to the Riverside County Public Health, dated March 8, 2016, which stated, "The Director of Staff Development received a phone call on Monday, March 7, 2016, at about 2 p.m. from (name of Registered Nurse 1 (RN 1)), at (name of GACH). She is the Director of Infection Control. It was reported that our Resident 1 tested positive for legionella disease." On March 29, 2016, a record review was conducted for Resident 1. The resident was admitted to the facility on April 10, 2014, with diagnoses including, "encounter for attention to gastrostomy (a tube inserted in the stomach wall to administer liquid food, fluids, and medications), and dementia (memory loss)." On March 29, 2016, at 11:15 a.m., an interview was conducted with the ADM, who stated she contacted RN 2 at the Riverside County Public Health on March 8, 2016, at 3:10 p.m., to notify RN 2 that Resident 1 had tested positive for legionella. The ADM further stated she was not instructed by RN 2 to notify CDPH of the diagnosis until after she received a fax from the Riverside County Public Health on March 24, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 92QW11 Facility ID: CA240000045 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055255 (X3) DATE SURVEY COMPLETED 02/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CORONA HEALTH CARE CENTER 1400 Circle City Dr Corona, CA 92879 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On March 29, 2016, at 11:45 a.m., a telephone interview was conducted with RN 2 at Riverside County Public Health, who stated she faxed a "Surveillance Plan," to the facility on March 24, 2016, which indicated, "...It is recommended that the facility notify Licensing and Certification (L&C) of the above mentioned legionella case... " During an interview conducted with RN 3, Supervisor at Riverside County Public Health, on March 29, 2016, at 12:58 p.m., she stated the facility had the ultimate responsibility to report even one case of legionella to CDPH because even one case is considered an outbreak. The facility policy and procedure titled, "Unusual Occurrence Reporting," revised December 2007, was reviewed. The policy indicated, "....Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 92QW11 Facility ID: CA240000045 If continuation sheet 4 of 4