Other·October 23, 2019

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 facility reported incident. Facility Reported Incident number CA00643084. Representing the California Department of Public Health: Surveyor 40000, HFEN. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident number CA00643084.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 08/12/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the 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: YQ9R11 Facility ID: CA240000045 If continuation sheet 1 of 7 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 07/12/2019 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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an allegation of physical abuse involving Resident A and Resident B was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. In addition, the facility failed to ensure a written report of investigation was provided to CDPH within five working days of the occurrence of the allegation of abuse. These failures had the potential to result in the delay in implementation of appropriate action and provision of protection to the residents and placed the residents at risk for further abuse. Findings: On June 24, 2019, at 2:44 p.m., CDPH received the document titled, "Report of Suspected Dependent Adult/Elder Abuse," by fax (a telephonic transmission). The document indicated, "...accused (Resident A) took off ashtray lid and hit victim (Resident B) in the hand and forearm causing bruising..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 2 of 7 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 07/12/2019 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 July 1, 2019, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident regarding a resident to resident altercation. On July 1, 2019, at 9:30 a.m., the Administrator (ADM) and the Director of Nursing (DON) were interviewed. The DON stated Resident B reported Resident A hit him several times on the right forearm and right hand while they were at the Assisted Living (AL) smoking patio, to Licensed Vocational Nurse (LVN) 1, on June 22, 2019, at 6:10 p.m. The DON stated Resident A was going through the trash can and Resident B approached Resident A asking him what he was looking for. The DON stated Resident A removed the metal lid cover from the trash can and hit Resident B with it on Resident B's right forearm and right hand. The DON stated Resident B sustained bruises on his right forearm and right hand. On July 1, 2019, Resident A's record was reviewed. Resident A was admitted to the facility on June 13, 2019, with diagnoses which included nicotine (a toxic substance in cigarettes) dependence and schizophrenia (mental disorder). The facility document titled, "HISTORY AND PHYSICAL EXAMINATION," dated June 18, 2019, indicated Resident A can make needs known but can not make medical decisions. The "IDT (Interdisciplinary Team) Progress Note," dated June 24, 2019, indicated, "...On 6/22/2019 (June 22, 2019) at around 6 pm (p.m.), charge nurse reported...Resident stated...he had hit with the cap of ash tray. Resident at Assisted Living witnessed another patient (Resident A) hitting this patient (Resident B)...alleged abuser (Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 3 of 7 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 07/12/2019 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 A)...started pounding his (Resident B) Right forearm and hand with trash can lid 3-5 times..." The "Progress Notes," dated June 25, 2019, indicated, "...BEHAVIORAL HEALTH NOTE...pt (patient - Resident A) stated that he "accidentally" hit the other resident (Resident B) with the ashtray..." On July 1, 2019, Resident B's record was reviewed. Resident B was admitted to the facility on May 16, 2017, with diagnoses which included chronic embolism (blod clot) and depression (mood disorder). The "Progress Notes," dated June 22, 2019, documented by LVN 1, indicated, "...resident (Resident B) reported that one of the residents on st 1 (station one) had hit him when on the right arm (sic). Resident stated that they were at the assisted living smoking area. The other resident (Resident A) grabbed the cap of the ash tray and started to hit him. Witnessed by other resident...from assisted living..." The facility document titled, "HISTORY AND PHYSICAL EXAMINATION," dated July 3, 2018, indicated Resident B had the capacity to understand and make decisions. On July 1, 2019, at 10:12 a.m., Resident A was observed sitting in his wheelchair at the AL smoking patio. Resident A was observed alert and oriented. On July 1, 2019, at 11:08 a.m., Resident B was observed and interviewed. Resident B was observed to be able to propel his wheelchair. Resident B stated he was in the AL smoking patio talking to other AL residents on June 22, 2019, at around 6 p.m. Resident B stated he saw Resident A digging in the trash can. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 4 of 7 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 07/12/2019 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 Resident B stated he went towards Resident A and asked him what he was looking for and Resident A suddenly hit him on his right forearm multiple times with the metal lid of the trash can. Resident B stated he went to LVN 1 to report the incident of Resident B hitting him. Resident B stated he showed LVN 1 his right arm with bruise. Resident B agreed to show his right arm and right hand. Resident B's right forearm was observed to have purplish discoloration with some areas fading measuring about eight by 18 centimeters (cm). Resident B's right hand was observed to have a purplish discoloration measuring seven by six and a half cm. On July 1, 2019, at 12:59 p.m., the DON was interviewed. The DON stated the altercation incident involving Resident A and Resident B happened on June 22, 2019, at around 6 p.m. The DON stated she was became aware of the altercation when she received the incident report on June 24, 2019. The DON stated the facility notified CDPH of the abuse through fax (a telephonic communication) on June 24, 2019, at 2:44 p.m. (44 hours after the altercation occurred). The DON stated CDPH should have been notified of the abuse within two hours from the time the facility was aware of the abuse. On July 8, 2019, at 2:13 p.m., LVN 1 was interviewed. LVN 1 stated Resident B reported to him, on June 22, 2019 at around 6 p.m., Resident A hit his right arm and hand with the metal lid cover of the trash can in the AL smoking area. LVN 1 stated Resident B was observed to have a bruise on the right forearm. LVN 1 stated if a resident reported an allegation of hitting, it should be considered as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 5 of 7 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 07/12/2019 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 abuse. LVN 1 stated the altercation incident involving Resident A hitting Resident B should have been reported to CDPH within two hours from the time the allegation of abuse was received by the facility. On July 8, 2019, at 2:41 p.m., RN supervisor was interviewed. RN supervisor stated the altercation incident between Resident A and Resident B was reported to her by LVN 1 on June 22, 2019, at around 6 p.m. RN Supervisor stated she did not know altercations between residents should be reported to CDPH. On July 8, 2019, at 10:03 a.m., CDPH received the facility's report of the complete investigation of the altercation involving Resident A and Resident B, dated July 8, 2019 (16 days after the alleged incident occurred). On July 9, 2019, at 10:41 a.m, the ADM was interviewed. The ADM stated the investigation summary report was faxed to CDPH on July 8, 2019. The ADM stated the investigation summary report faxed to CDPH should have been submitted to CDPH within five working days of the occurrence of the incident (on June 28, 2019). According to the "State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities CFR 483.5," revised November 22, 2017, the definition of abuse and willful were as follow: - "...Abuse, is defined at §483.5 as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish... Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 6 of 7 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 07/12/2019 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 abuse, and mental abuse..." - "...Willful, as defined at §483.5 and as used in the definition of "abuse," "means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm..." The facility policy and procedure titled, "Abuse Investigation and Reporting," revised July 2017, was reviewed. The policy indicated, "...All reports of abuse...shall be promptly reported to local, state and federal agencies...Findings of abuse investigations will also be reported...All alleged violations involving abuse...will be repoted by the facility Admninistrator, or his/her designee, to...The State licensing/certification agency responsible for surveying/licensing the facility...All alleged violation of abuse...will be reported immediately, but not later than...Two (2) hours if the alleged violation involves abuse...The Administrator, or his/her designee, will provide the appropriate agencies...with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YQ9R11 Facility ID: CA240000045 If continuation sheet 7 of 7