Other·March 4, 2020

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 annual recertification survey conducted from November 18, 2019, to November 21, 2019. Representing the California Department of Public Health: 41348, HFEN; 32192, HFEN; 37626, HFEN; 40988, HFEN; 42395, HFEN; 42498, HFEN; and 42573, HFEN. The facility census was 88.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/21/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. 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: C1PG11 Facility ID: CA240000045 If continuation sheet 1 of 44 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 11/21/2019 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 §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 2 of 44 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 11/21/2019 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 intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a written notification of transfer was provided to the residents or the residents' representative (RR), as well as the Office of the State Long-Term FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 3 of 44 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 11/21/2019 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 Care Ombudsman, when the residents were transferred to the general acute care hospital (GACH), for three of four residents reviewed for hospitalization (Residents 39, 21, and 30). This failure had the potential for the residents or the RR to not be aware of the reason/s for transfer/s, the location/s where the residents were transferred to, and the right to make an appeal to the appropriate agency timely. In addition, this failure had the potential for the Office of the State Long-Term Care Ombudsman to not be aware of and to not be able to inquire about the transfer/s. Findings: 1. On November 20, 2019, Resident 39's record was reviewed. Resident 39 was admitted to the facility on November 30, 2018, with diagnoses which included dementia (loss of reasoning skills and the ability to remember) and gastrostomy (surgical opening into the stomach). The "History and Physical Examination," dated November 18, 2019, indicated Resident 39 had the capacity to understand and make health care decisions. The document indicated Resident 39's family member was available to assist in decision making. The "Progress Notes," dated September 23, 2019, indicated Resident 39 was transferred to the GACH on September 23, 2019. There was no documented evidence Resident 39 or Resident 39's representative was notified in writing of Resident 39's transfer to the GACH on September 23, 2019. There was no documented evidence a written notification of Resident 39's transfer to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 4 of 44 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 11/21/2019 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 GACH on September 23, 2019, was provided to the Office of the State Long-Term Care Ombudsman. On November 21, 2019, at 2:11 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated when a residents was transferred to the GACH, the "Notice of Transfer/Discharge (T/D)" form for the resident would be filled up electronically, then a copy would be printed out and faxed (facsimile- transmission by phone) to the Office of the State Long-Term Care Ombudsman and placed in the resident's chart. The fax confirmation would be placed in the resident's chart. LVN 1 stated the facility would not provide a written notice of transfer to the resident or the RR when a resident was transferred to the GACH. LVN 1 stated if a resident or RR wanted a copy, the facility business office would take care of that. Resident 39's record was concurrently reviewed with LVN 1. LVN 1 stated Resident 39's T/D form for September 23, 2019, did not have the check box for the "Signature Section...Copy to: State LTC Ombusman Office..." marked. LVN 1 stated there was no documentation a written notice of transfer was provided to Resident 39 or Resident 39's representative and to the Office of the State Long-Term Care Ombudsman when Resident 39 was transferred to the GACH on September 23, 2019. On November 21, 2019, at 9:45 a.m., the Social Services Assistant (SSA) was interviewed. The SSA stated the facility currently has no tracking process to ensure the Office of the State Long-Term Care Ombudsman has been notified of a resident's transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 5 of 44 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 11/21/2019 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 November 21, 2019, at 9:49 a.m., the Social Services Supervisor (SSS) was interviewed. The SSS stated the facility did not provide a written notice of transfer to the resident or the RR when a resident was transferred to the GACH. The SSS stated the facility did not provide written notification of a resident's transfer to the Office of the State Long-Term Care Ombudsman. The SSS stated the facility did not mail out written notifications of residents' transfers to the RR. The SSS stated the facility did not have a process to ensure a written notice of transfer was given to the resident or RR when a resident was transferred to a GACH. 2. On November 18, 2019, at 11:13 a.m., Resident 21 was observed awake, alert, and sitting on the edge of his bed. In a concurrent interview with Resident 21, Resident 21 stated he fell about six months ago. Resident 21 stated he went to the GACH for tests. On November 19, 2019, Resident 21's record was reviewed. Resident 21 was admitted to the facility on March 3, 2017, with diagnoses which included diabetes (abnormal blood sugar). The "History and Physical Examination," dated September 11, 2019, indicated the resident had the capacity to understand and make decisions. The untitled document, dated October 4, 2019, at 1:55 p.m., indicated, "...Send resident to (name of general acute care hospital) for further eval (evaluation) d/t (due to) s/p (status post) unwitnessed fall..." There was no documented evidence a written notice of transfer was provided to Resident 21, Resident 21's representative, or the Office of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 6 of 44 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 11/21/2019 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 the State Long-Term Care Ombudsman when Resident 21 was transferred to the GACH on October 4, 2019. On November 20, 2019, at 10:01 a.m., an interview was conducted with LVN 2. LVN 2 stated if the RR was not in the facility when the resident was transferred to the GACH, the staff would notify the RR by telephone. LVN 2 stated the licensed nurses did not provide written notice of transfer to the resident or the RR when a resident was transferred to the GACH. On November 20, 2019, at 10:07 a.m., an interview and concurrent record review was conducted with LVN 2. LVN 2 stated there was no documentation written information was provided to Resident 21 or Resident 21's representative regarding Resident 21's transfer to the GACH on October 4, 2019. LVN 2 further stated there was no documentation the Office of the State Long-Term Care Ombudsman was notified regarding the transfer of Resident 21 to the GACH on October 4, 2019. On November 20, 2019, at 10:13 a.m., an interview was conducted with the SSS. The SSS stated the facility process when a resident was transferred to the GACH, was for the nursing staff to provide notification to the resident or the RR. The SSS stated the nursing staff were also to provide the notification to the State Long-Term Care Ombudsman. The SSS further stated the facility process was for social service to notify the Office of the State Long-Term Care Ombudsman for planned discharges only. On November 20, 2019, at 3:37 p.m., an interview was conducted with LVN 1. LVN 1 stated the facility did not provide a written notice of transfer to the resident or the RR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 7 of 44 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 11/21/2019 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 when a resident was transferred to the GACH. 3. On November 19, 2019, Resident 30's record was reviewed. Resident 30 was originally admitted to the facility on September 6, 2019, with diagnoses including chronic obstructive pulmonary disease (a lung disease) and gastro-esophageal reflux disease (regurgitation of stomach fluid/contents). The untitled document, dated September 28, 2019, at 7:51 a.m., indicated, "...send pt (patient) to ER (emergency room), (name of GACH) r/t (related to) respiratory distress..." There was no documented evidence Resident 30 or Resident 30's representative received a written notice of transfer or discharge when Resident 30 was transferred to the GACH on September 28, 2019. There was no documented evidence a copy of the notice of transfer or discharge was provided to the Office of the State Long-Term Care Ombudsman when Resident 30 was transferred to the GACH on September 28, 2019. On November 20, 2019, at 9:38 a.m., the record of Resident 30 was reviewed with the Medical Records Supervisor (MRS). The MRS confirmed there was no documentation a written notice of transfer or discharge was completed and provided to Resident 30 or Resident 30's representative, and to the Office of the State Long-Term Care Ombudsman. During a concurrent interview with the MRS, the MRS stated when Resident 30 was transferred to the GACH on September 28, 2019, the notice of transfer or discharge should have been completed and a written copy should have been provided to Resident 30 or Resident 30's representative, and to the Office FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 8 of 44 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 11/21/2019 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 of the State Long-Term Care Ombudsman. The facility policy and procedure titled, "Transfer or Discharge Notice," revised December 2016, was reviewed. The policy indicated, "...Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge...The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy...A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman..."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 12/21/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment tool) was accurate, for one of five residents reviewed for assessments (Resident 46). This failure resulted in an inaccurate assessment for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 9 of 44 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 11/21/2019 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 46. Findings: On November 19, 2019, Resident 46's records were reviewed. Resident 46 was admitted to the facility on September 19, 2019. The "History and Physical Examination," dated September 20, 2019, indicated Resident 46 had diagnoses that included atrial fibrillation (Afib- abnormal heart beat), hypertension (high blood pressure), and congestive heart failure (fluid around the heart causing it to pump inefficiently). The "Order Summary Report," included a physician's order which indicated, "Apixaban (an anticoagulant- blood thinner) Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for Afib...Active 9/20/2019 09:00 (started September 20, 2019 at 9:00 a.m.)..." The Medication Administration Record (MAR) for September 2019, indicated Apixaban was administered to Resident 46 starting on September 20, 2019. The MDS assessment, dated September 26, 2019, indicated Resident 46 was not receiving an anticoagulant (Section N for medications received indicated "0 (zero)" days of anticoagulant use). On November 21, 2019, at 3:48 p.m., a review of Resident 46's record was conducted with the MDS Nurse (MDSN). In a concurrent interview, the MDSN stated Resident 46 had orders for Apixaban. The MDSN verified Resident 46 started receiving Apixaban on September 20, 2019. The MDSN verified the MDS, dated September 26, 2019, indicated the assessment for Resident 46 was coded as the resident was not receiving an anticoagulant. The MDSN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 10 of 44 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 11/21/2019 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 stated Resident 46's MDS should have been coded as Resident 46 had received an anticoagulant for at least five (5) days, "but I did not do it." The Resident Assessment Instrument (RAI- a reference manual for MDS) Volume 3.0 Manual was reviewed. The document indicated, "...NO410E...Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7 (seven)-day look-back period (time period for observation of resident) (or since admission/entry or reentry if less than 7 days)..."

F655 SS=E Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 12/21/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 11 of 44 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 11/21/2019 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 comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: 7. On November 19, 2019, Resident 24's record was reviewed. Resident 24 was admitted to the facility on May 23, 2019, with diagnoses which included dysphagia following a cerebral infarction (trouble swallowing after a stroke), dementia (memory loss), anxiety disorder, and schizophrenia. There was no documented evidence the BCP summary was provided to Resident 24 or Resident 24's representative. On November 21, 2019, at 1:53 p.m., an interview and concurrent record review was conducted with the MDSC. The MDSC stated there was no documentation the BCP summary was given to Resident 24 or Resident 24's representative. The MDSC stated BCP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 12 of 44 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 11/21/2019 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 summaries should be given to the resident or the RR and documented in the chart. On November 21, 2019, at 2:01 p.m., an interview and concurrent record review was conducted with the SSA. The SSA stated there needed to be documentation the BCP summary was offered to the resident or the RR. The SSA stated there was no documentation a copy of the BCP summary was provided to Resident 24 or Resident 24's representative. The facility policy and procedure titled "Care Plans-Baseline," revised December 2016, was reviewed. The policy indicated, "...The resident and their representative will be provided a summary of the baseline care plan..."Based on interview and record review, the facility failed to ensure written summaries of the baseline care plans (BCP) were provided to the residents and the residents' representatives (RR) for seven of 21 residents reviewed (Residents 385, 53, 44, 40, 62, 31, and 24). This failure had the potential for the residents or the RR's to not be aware of the services and treatments being provided to the residents. In addition, this failure had the potential for the resident/s or the RR's to not be able to participate in the residents' care and treatments. Findings: 1. On November 19, 2019, the record of Resident 385 was reviewed. Resident 385 was admitted to the facility on September 16, 2019, with diagnoses which included fracture of the right hip, chronic kidney disease (condition resulting in gradual loss of the kidney's function), hypothyroidism (low level of thyroid hormone), and muscle weakness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 13 of 44 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 11/21/2019 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 November 19, 2019, at 4:18 p.m., the record of Resident 385 was reviewed with the Minimum Data Set (MDS- a standardized assessment tool) Coordinator (MDSC). In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 385 or Resident 385's representative. 2. On November 20, 2019, the record of Resident 53 was reviewed. Resident 53 was admitted to the facility on July 26, 2019, with diagnoses which included chronic obstructive pulmonary disease (lung disease), heart failure (a heart condition), Parkinson's disease (a progressive disease involving the nerves resulting in tremors and muscle rigidity), and schizophrenia (a mental disorder). On November 20, 2019, at 3:30 p.m., the record of Resident 53 was reviewed with the MDSC. In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 53 or Resident 53's representative. 3. On November 20, 2019, the record of Resident 44 was reviewed. Resident 44 was admitted to the facility on September 17, 2019, with diagnoses which included bipolar disorder (mood disorder), diabetes mellitus (abnormal blood sugar), chronic obstructive pulmonary disease (COPD, a lung disease), and difficulty walking. On November 20, 2019, at 3:11 p.m., the record of Resident 44 was reviewed with the MDSC. In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 44 or Resident 44's representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 14 of 44 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 11/21/2019 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 4. On November 20, 2019, the record of Resident 40 was reviewed. Resident 40 was admitted to the facility on September 13, 2019, with diagnoses which included diabetes mellitus, hypertension (high blood pressure), major depressive disorder (a mood disorder), and hemiplegia and hemiparesis (paralysis and weakness of one side of the body). On November 20, 2019, at 10:46 a.m., the record of Resident 40 was reviewed with the MDSC. In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 40 or Resident 40's representative. On November 20, 2019, at 3:20 p.m., the Social Service Assistant (SSA) was interviewed. The SSA stated the facility should document in the interdisciplinary team (IDT) meeting notes when the facility provided a copy of the BCP summary to the resident or the RR. SSA stated the facility should document in the IDT notes if the resident or the RR declined to receive a copy of the BCP summary. 5. On November 21, 2019, the record of Resident 62 was reviewed. Resident 62 was admitted to the facility on October 9, 2019, with diagnoses which included major depressive disorder (mood disorder), COPD, heart failure, hypothyroidism, bipolar disorder and anxiety disorder (a mood disorder). On November 21, 2019, at 9:45 a.m., the record of resident 62 was reviewed with the MDSC. In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 62 or Resident 62's representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 15 of 44 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 11/21/2019 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 6. On November 21, 2019, the record of Resident 31 was reviewed. Resident 31 was initially admitted to the facility on August 24, 2019, with diagnoses which included left hip replacement surgery, stage four pressure ulcer of the sacral region (deep wound on the lower back area due to pressure which may extend to the bones), hypothyroidism, heart failure, and muscle weakness. On November 21, 2019, at 3:59 p.m., the record of Resident 31 was reviewed with the MDSC. In a concurrent interview with the MDSC, the MDSC stated there was no documentation a copy of the BCP summary was provided to Resident 31 or Resident 31's representative.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 12/21/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 16 of 44 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 11/21/2019 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 (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a care plan was developed and implemented to address Resident 46's anticoagulant use and/or the diagnosis of atrial fibrillation (Afib- abnormal heart beat). This failure had the potential for the resident to not receive the care and services necessary to maintain his highest possible level of function relative to Resident 46's use of anticoagulants and the diagnosis of Afib. Findings: On November 19, 2019, Resident 46's records were reviewed. Resident 46 was admitted to the facility on September 19, 2019. The "History and Physical Examination," dated September 20, 2019, indicated Resident 46 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 17 of 44 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 11/21/2019 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 had diagnoses that included Afib, hypertension (high blood pressure), and congestive heart failure (fluid around the heart causing it to pump inefficiently). The "Order Summary Report," included a physician's order which indicated, "Apixaban (an anticoagulant- blood thinner) Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for Afib...Active 9/20/2019 09:00 (started on September 20, 2019 at 9:00 a.m.)." The medication administration record (MAR) for September 2019, indicated Apixaban was administered to Resident 46 starting September 20, 2019. Resident 46's care plans were reviewed. There was no documented evidence care plans addressing Resident 46's use of an anticoagulant and Resident 46's diagnosis of Afib were developed and implemented. On November 20, 2019, at 3:48 p.m., a review of Resident 46's record was conducted with the MDS (MDS- a standardized assessment tool) Nurse (MDSN). In a concurrent interview, the MDSN stated Resident 46 had orders for Apixaban. The MDSN verified Resident 46 started receiving Apixaban on September 20, 2019. The MDSN verified there was no documentation care plans to address Resident 46's use of anticoagulant and the diagnosis of Afib were developed and implemented. The MDSN stated she did Resident 46's admission MDS, dated September 26, 2019, and developed the care area assessments. The MDSN stated she did not initiate a care plan for Resident 46's use of an anticoagulant. On November 20, 2019, at 3:52 p.m., the MDS Coordinator (MDSC) was interviewed. The MDSC stated after a resident was admitted to the facility, the chart would be reviewed by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 18 of 44 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 11/21/2019 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 interdisciplinary team (IDT) the next day and during a weekly chart review (by day seven). Areas that would be reviewed included the resident's medical diagnoses, the medication orders, and the care plans. The MDSC stated the care plans for Resident 46's use of an anticoagulant and Resident 46's diagnosis of Afib were missed. The MDSC stated this should have been caught at any of the times Resident 46's chart was reviewed. The MDSC stated it should have also been caught when Resident 46's admission MDS was done. The facility's policy titled, "Care Planning Interdisciplinary Team," revised September 2013, was reviewed. The policy indicated, "...Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident...A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS)..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 12/21/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident received the intravenous fluids (IVF- fluids administered through the vein) as ordered by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 19 of 44 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 11/21/2019 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 the physician, for one of 21 residents reviewed (Resident 384). This failure had the potential for Resident 384 to not receive the correct dose of IVF which could lead to dehydration or fluid overload (excess fluid in the body). Findings: On November 18, 2019, at 11:27 a.m., Resident 384 was observed lying in bed. Resident 384 was observed to have IVF being administered via gravity with a regulator (tubing with attached device to set the flow rate) that was set and was administering at a rate of 80 milliliter per hour (ml/hr) through the peripheral intravenous access on Resident 384's left arm. On November 18, 2019, at 1:42 p.m., Resident 384 was observed in his room with Registered Nurse (RN) 1. RN 1 stated the label on the IVF currently infusing on Resident 384's left arm indicated the flow rate was supposed to be at 70 ml/hr. RN 1 confirmed the IVF of Resident 384 was being administered at 80 ml/hour. RN 1 stated the rate should be at 70 ml/hour. On November 21, 2019, the record of Resident 384 was reviewed. Resident 384 was admitted to the facility on November 14, 2019, with diagnoses which included a fracture of the left femur (hip bone), hypertensive heart disease with heart failure (a heart condition due to high blood pressure), and acute kidney failure (loss of kidney function). The record of Resident 384 included an untitled document, dated November 17, 2019, which included a physician's order indicating, "Normal Saline 0.9 % (percent) IV at 70 ml/hour x (times) 3 (three) liters..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 20 of 44 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 11/21/2019 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

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/21/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a resident was turned every two hours as ordered by the physician, for one of one resident (Resident 484) reviewed for pressure ulcer (bed sores). This failure increased the potential for Resident 484 to develop further skin breakdown and bed sores. Findings: On November 18, 2019, at 11:37 a.m., Resident 484 was observed lying on her back while in bed. Resident 484 was observed to not have any pillow under either of her hips or back. On November 19, 2019, Resident 484's record was reviewed. The record indicated Resident 484 was admitted to the facility on November 11, 2019, with diagnoses including diabetes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 21 of 44 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 11/21/2019 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 mellitus (abnormal blood sugar), kidney failure (when the kidneys lose the ability to filter waste from the blood sufficiently), and dementia (memory loss). The document titled, "Order Summary Report," indicated, "...Active Orders as of 11/20/2019 (November 20, 2019)...diagnoses...pressure ulcer of Left Buttock, Stage 1 (one; localized area with intact skin and non-blanchable [color would not return after release of pressure on the area])...Pressure Ulcer of Right Buttocks, stage 1..." The document also included a physician's order, dated November 12, 2019, which indicated, "...Turn and reposition q (every) 2 (two) hours every shift for comfort and relief pressure..." The document titled, "Care Plan," dated November 17, 2019, indicated, "...The resident has pressure ulcer to left buttocks Stage 2 (with shallow open skin areas) R/T (related to) immobility...turn and reposition at least Q 2 hours..." There was no documented evidence Resident 484 was turned every two hours on November 20, 2019, as ordered by the physician. On November 20, 2019, at 8:20 a.m., Resident 484 was observed lying on her back while in bed. On November 20, 2019, at 10:20 a.m., Resident 484 was observed lying on her back while in bed. On November 20, 2019, at 12 p.m., Resident 484 was observed lying on her back while in bed. On November 20, 2019, at 12:10 p.m., Certified Nurse Assistant (CNA) 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 22 of 44 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 11/21/2019 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 interviewed. CNA 1 stated she turned Resident 484 at 10 a.m., and was going to turn Resident 484 at 12:10 p.m. CNA 1 could not state where she documented Resident 484 was being turned. CNA 1 stated Resident 484 should be turned every two hours. On November 20, 2019, at 12:17 p.m., an interview and concurrent record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated she was not aware Resident 484 had a Stage 2 wound on her left buttocks. LVN 3 also stated she did not see Resident 484's pressure ulcer listed on the document titled, "Turning and Repositioning," dated November 20, 2019. LVN 3 stated Resident 484 should have been turned every two hours according to the physician's order. On November 20, 2019, at 1:11 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated Resident 484 should be turned every two hours according to the physician's order. The facility policy and procedure titled, "Prevention of Pressure Ulcers/Injuries," revised July 2017, was reviewed. The policy indicated, "...Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable...Reposition resident as indicated on the care plan...At least every two hours, reposition residents who are reclining and dependent on staff for repositioning..."

F698 SS=E Dialysis CFR(s): 483.25(l) FORM CMS-2567(02-99) Previous Versions Obsolete

F698 Event ID: C1PG11 12/21/2019 Facility ID: CA240000045 If continuation sheet 23 of 44 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 11/21/2019 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 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure written contracts were drawn with the dialysis facilities (a facility that provided dialysis [removing toxins from the blood] services) prior to the provision of dialysis, for four of four residents reviewed for dialysis (residents 484, 52, 34, and 76). This failure had the potential for the residents to not receive dialysis care as needed and as ordered by their physicians. Findings: On November 17, 2019, at 3:30 p.m., an interview was conducted with the Administrator (ADM). The ADM stated the facility used three dialysis facilities and named the three dialysis facilities (DC 1, DC 2, and DC 3). The ADM stated she did not have copies of written contracts with the dialysis facilities available at this time. On November 18, 2019, at 4:35 p.m., an interview was conducted with the ADM. The ADM stated she had a written contract with DC 2 available, but was unable to provide copies of contracts for DC 1 and DC 3. On November 20, 2019, at 9:15 a.m., an interview with the ADM was conducted. The ADM stated there were four residents who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 24 of 44 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 11/21/2019 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 received dialysis treatment. The ADM stated two residents received treatment at DC 3, one resident at DC 1, and one resident at DC 2. The ADM stated she did not have the written contract with DC 1 available. On November 21, 2019, at 8:30 a.m., an interview was conducted with the ADM. The ADM stated the written dialysis contract with DC 1 was available but was only a draft. The ADM stated the written contract needed to be signed by her and then e-mailed back to the dialysis facility. On November 21, 2019, at 9:53 a.m., an interview was conducted with the ADM. The ADM stated there were no written contracts on file at DC 1 and DC 3 for dialysis with the facility. The ADM stated the contracts with DC 1 and DC 3 were being written. The ADM further stated DC 3's contract needed to go to the corporate office to be reviewed before it would be available for signing. The facility policy and procedure titled, "EndStage Renal Disease, Care of a Resident with," revised September 2010, indicated, " ...Education and training of staff in the care of...dialysis residents may be managed by the contracted dialysis facility...Agreements between this facility and the contracted ESRD (End-Stage Renal Disease; condition for which dialysis would be provided) facility include all aspects of how the resident's care will be managed, including...How the care plan will be developed and implemented...How information will be exchanged between the facilties, and...Responsibility for waste handling, sterilization and disinfection of equipment..." The document titled, "Center for Medicaid and State Operations/Survey and Certification Group Ref: S&C: 04-24," dated March 19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 25 of 44 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 11/21/2019 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 2004, indicated, "...Under the ESRD regulations...written documentation is required which specifies the terms and responsibilities of various providers of services. Therefore, to ensure that there is adequate coordination of care to effectively provide home dialysis training and support services to residents of LTC (long Term Care) facilities, the ESRD facility will enter into a written coordination agreement with each LTC facility in which home dialysis patients reside. The purpose of this agreement is to coordinate the provision of such specific services to maximize patient safety and program efficiency..."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 12/21/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 26 of 44 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 11/21/2019 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 stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately, when: 1. The bubble pack containing amlodipine (medication to treat high blood pressure) tablets, labeled with Resident 21's name, was observed to not have hold (do not give) parameters, as ordered by the physician. This failure had the potential for Resident 21 to not receive the medication as ordered by the physician. 2. The following medications were found in the cart, readily available for use: a. Ten tablets of colchicine (anti-gout [inflammation of the joint due to excess uric acid] medication), was observed labeled with Resident 21's name and an expiration date of August 28, 2019; and b. 14 tablets of midodrine (medication used to treat low blood pressure), was observed labeled with Resident 27's name and an expiration date of October 20, 2019. These failures had the potential for the residents to receive expired medications. Findings: 1. On November 20, 2019, at 9:30 a.m., a medication administration observation was conducted in Station 2 with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed to prepare medications for Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 27 of 44 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 11/21/2019 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 21 into a medicine cup which included one tablet of amlodipine five (5) milligram (mg- unit of measurement). During a concurrent review of the bubble pack (medication packaging which contained designated sealed compartments, or spaces for medicines to be taken at particular times of the day) containing amlodipine, the bubble pack label indicated Resident 21's name and the instructions, "AMLODIPINE TAB (tablet) 5 MG TAKE ONE TABLET BY MOUTH ONCE DAILY FOR HYPERTENSION (high blood pressure)." There was no documented evidence the label of the bubble pack containing the amlodipine tablets indicated a hold parameter. The "Medication Administration Record (MAR)" for Resident 21 was concurrently reviewed with LVN 1. The MAR included a medication order which indicated, "Norvasc Tablet 5 MG (AmLODIPine Besylate) Give 1 tablet by mouth one time a day for HTN (hypertension) Hold for SBP (systolic blood pressure- peak blood pressure during a heart contraction) < (less than) 110." LVN 1 was concurrently interviewed. LVN 1 stated there were no hold parameters on the bubble pack label of amlodipine. On November 20, 2019, at 3:13 p.m., LVN 1 was interviewed, LVN 1 stated labels on medications dispensed by the facility's pharmacy should match what was on the MAR, including parameters and special instructions, "basically what the order says." On November 20, 2019, at 11:11 a.m., Resident 21's record was reviewed. Resident 21 was admitted to the facility on March 3, 2017. The "History and Physical Examination," dated September 11, 2019, indicated Resident 21 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 28 of 44 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 11/21/2019 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 had diagnoses which included hypertension. The "Order Summary Report," dated November 21, 2019, included a physician's order which indicated, "Norvasc Tablet 5 MG (AmLODIPine Besylate) Give 1 tablet by mouth one time a day for HTN Hold for SBP < 110." The facility policy titled, "Labeling of Medication Containers," revised April 2007, was reviewed. The policy indicated, "...All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations...Labels for individual drug containers shall include all necessary information, such as...Appropriate accessory and cautionary statements..." The facility policy titled, "Storage of Medications," revised April 2007, was reviewed. The policy indicated, "...Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing..." 2. On November 21, 2019 at 2:28 p.m., an inspection of Station 2 medication cart was conducted with LVN 1. The following were observed: a. Ten tablets of colchicine in a bubble pack were observed to be in the left bottom drawer of the medication cart, readily available for use. The label of the bubble pack containing colchicine was concurrently reviewed. The label indicated Resident 21's name and the instructions, "COLCHICINE TAB 0.6 MG TAKE ONE TABLET BY MOUTH TWICE DAILY AS NEEDED..." The label indicated an expiration date of August 28, 2019. LVN 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 29 of 44 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 11/21/2019 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 concurrently interviewed. LVN 1 stated the colchicine tablets were expired. LVN 1 further stated the medications should not be in the medication cart because they were expired and should not be readily available for use. On November 21, 2019, Resident 21's record was reviewed. Resident 21 was admitted to the facility on March 3, 2017, with diagnoses that included gout. The "Order Summary Report," dated November 21, 2019, included a physician's order which indicated, "Colcrys Tablet 0.6 MG (Colchicine) Give 0.6 mg by mouth two times a day for gout..." b. 14 tablets of midodrine in a bubble pack were observed to be in the left bottom drawer of the medication cart, readily available for use. The label of the bubble pack containing midodrine was reviewed. The label indicated Resident 27's name and the instructions, "MIDODRINE TAB 5 MG TAKE ONE (1) TABLET BY MOUTH EVERY 24 HOURS AS NEEDED FOR SBP < 95..." The label indicated an expiration date of October 20, 2019. LVN 1 was concurrently interviewed. LVN 1 stated the midodrine tablets were expired. LVN 1 further stated the medications should not be in the medication cart because they were expired and should not be available for use. On November 21, 2019, Resident 27's record was reviewed. Resident 27 was admitted to the facility on November 10, 2016, with diagnoses that included hypotension (low blood pressure) and heart failure. The "Order Summary Report," dated November 21, 2019, included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 30 of 44 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 11/21/2019 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 physician's orders which indicated, "Midodrine HCl (hydrochloride) Tablet 5 MG give 1 tablet by mouth as needed for hypotension X BID (twice a day)..." The facility's undated policy and procedure titled, "Expiration Dates/Guidelines," was reviewed. The policy indicated, "...To ensure maximum effect of medications, expiration dates are recommended on all containers. In all cases, medications should not be used past the expiration date from the manufacturer..." The facility policy titled, "Storage of Medications," revised April 2007, was reviewed. The policy indicated, "...the facility shall not use discontinued, outdated (expired), or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed..."

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 12/21/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 31 of 44 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 11/21/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure dietary staff were knowledgeable about safe food practices when two dietary staff were not able to verbalize the cool down process (procedure of cooling down of hot foods which will not be served immediately). This failure had the potential to result in foodborne illnesses for 85 out of 88 residents who ate food prepared in the kitchen. Findings: On November 20, 2019, at 8:35 a.m., a follow up inspection in the kitchen was conducted. At 8:49 a.m., Cook 2 was interviewed. Cook 2 was unable to verbalize the proper cool down process. On November 20, 2019, at 8:55 a.m. the Dietary Supervisor was interviewed. The DS stated she was not sure about the total hours for cooling down of hot foods. The facility policy titled, "COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS," dated 2018, was reviewed. The policy indicated, "...Cooked potentially hazardous foods shall be cooled and reheated to ensure food safety...Cool cooked food from 140 degrees Fahrenheit to 70 degrees Fahrenheit within two hours. Then cool from 70 degrees Fahrenheit to 41 degrees Fahrenheit or less in an additional four hours for a total cooling time of six hours..."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete

F803 Event ID: C1PG11 12/21/2019 Facility ID: CA240000045 If continuation sheet 32 of 44 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 11/21/2019 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 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the menu for the renal diet and the appropriate scoop size used for the pureed small portions were being followed during tray line service. These failures increased the potential for the residents to not receive the recommended food and nutrition. Findings: On November 20, 2019, between 12:10 p.m. to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 33 of 44 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 11/21/2019 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 1:05 p.m., a tray line observation was conducted. Cook 1 was observed to not add a wheat roll on each tray for three out of four residents who were on renal diets. Cook 1 was observed to use the half (1/2) cup scoop for the chicken cacciatore and pasta with garlic and herbs for two residents with small portion pureed diet trays. During a concurrent interview with Cook 1 and the Dietary Supervisor (DS), Cook 1 and the DS confirmed the regular scoops (1/2 cup) were used for the small pureed portion servings for the chicken cacciatore and pasta with garlic and herbs instead of using the 1/4 cup scoop. Cook 1 confirmed the wheat roll was not provided to three out of four residents who were on renal diet. On November 20, 2019, the "Fall Menu" spread sheet (a guide for cooks to follow with the menu and serving sizes for different types of diets) for lunch on November 20, 2019, was reviewed. The menu indicated one wheat roll was to be served for residents who were on renal diet. The menu indicated the pureed small portions scoop size for chicken cacciatore and pasta with garlic and herbs were 1/4 (one fourth) cup. On November 20, 2019, the "Compact Roster Form" (list of residents with ordered diets) was reviewed. The form indicated there were four residents who were on renal diet, and there were two residents who were on pureed small portion diet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 34 of 44 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 11/21/2019 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 The facility policy titled, "PORTION SIZES," dated 2018 was reviewed. The policy indicated, "...Various portion sizes of the food served will be available to better meet the needs of the residents...the small...portion servings will be served as printed on the cook's spreadsheets for every meal..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 12/21/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation. interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when the kitchen floor had brown particles, the kitchen racks had chipped paint and one of the bottom shelves was rusted, and the top of the ice machines had brownish/blackish colored FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 35 of 44 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 11/21/2019 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 particles. These failures had the potential to cause food borne illnesses in the vulnerable residents of the facility who were served food from the kitchen. Findings: On November 18, 2019, starting at 8:50 a.m., an initial kitchen observation was conducted with the Dietary Supervisor (DS). The following were observed: -Three kitchen racks containing pots, pans, baking trays, and other clean kitchen utensils were observed to have multiple areas of chipped paint; -The bottom shelf of one of the three kitchen racks was observed to be rusted; -There were dry and brown colored particles on the floor under the two-compartment sink; -There were dry and brown colored particles on the floor under the kitchen rack located near the stove; and -The top portion of the two ice machines were observed to have brownish/blackish colored residue. During a concurrent interview with the DS, the DS confirmed there were dry and brown particles on the floor and brownish/blackish residue on top of the ice machines. The DS confirmed the storage racks were rusted and had chipped paint. The DS stated the kitchen staff should clean the kitchen floor and the external portions of the ice machines every day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 36 of 44 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 11/21/2019 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 The facility policy titled, "SANITATION," dated 2018, was reviewed. The policy indicated, "...Employees are to alert the FNS (Food and Nutrition Service) Director immediately to any equipment needing repair...The FNS Director... will report any equipment needing repair to the maintenance man...The FNS Director will write the cleaning schedule...All...counters, shelves...shall be kept clean, maintained in good repair and shall be free from breaks, corrosions...cracks and chipped areas...The kitchen staff is responsible for all the cleaning..."

F840 SS=E Use of Outside Resources CFR(s): 483.70(g)(1)(2)

F840 12/21/2019 §483.70(g) Use of outside resources. §483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section. §483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and (ii) The timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure written FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 37 of 44 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 11/21/2019 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 contracts were drawn with the dialysis facilities (a facility that provides dialysis [removing toxins from the body] services) prior to the provision of dialysis for four of four residents reviewed for dialysis (residents 484, 52, 34, and 76). This failure had the potential for the residents to not receive dialysis care as needed and as ordered by their physicians. Findings: On November 17, 2019, at 3:30 p.m., an interview was conducted the Administrator (ADM). The ADM stated the facility used three dialysis facilities (DC 1, DC 2, and DC 3). The ADM stated she did not have written dialysis contracts with the dialysis facilities available at this time. On November 18, 2019, at 4:35 p.m., an interview was conducted with the ADM. The ADM stated she had a written contract with DC 2 available, but was unable to provide copies of written contracts with DC 1 and DC 3. On November 20, 2019, at 9:15 a.m., an interview with the ADM was conducted. The ADM stated there were four residents who received dialysis treatment. The ADM stated two residents received treatment at DC 3, one resident at DC 1 and one resident at DC 2. The ADM stated she did not have the contract for DC 1 available. On November 21, 2019, at 8:30 a.m., an interview was conducted with the ADM. The ADM stated the dialysis contract with DC 1 was available but was only a draft. The ADM stated the contract needed to be signed by her and then e-mailed back to the dialysis facility. On November 21, 2019, at 9:53 a.m., an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 38 of 44 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 11/21/2019 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 interview was conducted with the ADM. The ADM stated there were no contracts on file at DC 1 and DC 3 for dialysis with the facility. The ADM stated the contracts for DC 1 and DC 3 were being written. The ADM further stated DC 3's contract needed to go to the corporate office to be reviewed before it would be available for signing. The facility policy and procedure titled, "EndStage Renal Disease, Care of a Resident with," revised September 2010, indicated, "Education and training of staff in the care of...dialysis residents may be managed by the contracted dialysis facility...Agreements between this facility and the contracted ESRD (End-Stage Renal Disease, a condition for which dialysis would be performed) facility include all aspects of how the resident's care will be managed, including...How the care plan will be developed and implemented...How information will be exchanged between the facilities, and...Responsibility for waste handling, sterilization and disinfection of equipment..." The document titled "Center for Medicaid and State Operations/Survey and Certification Group Ref: S&C: 04-24," dated March 19, 2004 indicated "...Under the ESRD regulations...written documentation is required which specifies the terms and responsibilities of various providers of services. Therefore, to ensure that there is adequate coordination of care to effectively provide home dialysis training and support services to residents of LTC (long Term Care) facilities, the ESRD facility will enter into a written coordination agreement with each LTC facility in which home dialysis patients reside. The purpose of this agreement is to coordinate the provision of such specific services to maximize patient safety and program efficiency..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 39 of 44 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 11/21/2019 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

F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/21/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 40 of 44 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 11/21/2019 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) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure infection control and prevention procedures were implemented, for one of 21 residents (Resident 484) reviewed for infection control. This failure increased the potential to result in cross contamination of Resident 484's wounds. Findings: On November 19, 2019, Resident 484's record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 41 of 44 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 11/21/2019 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 was reviewed. The record indicated Resident 484 was admitted to the facility on November 11, 2019, with diagnoses including diabetes (abnormal blood sugar), kidney failure (when the kidneys lose the ability to filter waste from the blood sufficiently), and dementia (memory loss). The document titled, "Order Summary Report," indicated, "...Active Orders as of 11/20/2019 (November 20, 2019)...diagnoses...pressure ulcer of Left Buttock, Stage 1 (one; localized area with intact skin and non-blanchable [color would not return after release of pressure on the area] )...Pressure Ulcer of Right Buttocks, stage 1...The document also included a physician's order, dated November 12, 2019, which indicated, "...Turn and reposition q (every) 2 (two) hours every shift for comfort and relief pressure..." The document titled, "Order Summary Report," dated November 17, 2019, indicated, "Cleanse left buttock pressure injury stage II (two) with NS (normal saline) or Wound cleanser (solution used to clean the wound), pat dry, apply Xeroform (absorbent fine mesh gauze) and cover with dry dressing every day shift for 21 Days Monitor s/s (signs and symptoms) of infection and notify MD." On November 20, 2019, at 11:22 a.m., the Treatment Nurse (TN) was observed providing wound care treatment on Resident 484's stage 2 pressure ulcer (shallow open ulcer) on the left buttocks. After the TN performed wound care on Resident 484's stage 2 pressure ulcer on the left buttocks, the TN was observed to then proceed to perform wound care on Resident 484's abdominal fold (area of skin under the belly button). The TN was observed to not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 42 of 44 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 11/21/2019 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 perform hand hygiene (cleaning of hands to reduce spread of infection) in between performing wound care on Resident 484's left buttocks pressure ulcer and performing wound care on Resident 484's abdominal fold wound. Then, the TN was observed to perform wound care on Resident 484's percutaneous endoscopic gastrostomy tube site (PEG - a tube surgically placed into the stomach for feeding) after performing wound care on Resident 484's abdominal fold wound. The TN was observed to not perform hand hygiene in between performing wound care on Resident 484's abdominal fold wound and performing wound care on Resident 484's PEG tube site. On November 20, 2019, at 12:36 p.m., the TN was interviewed. The TN stated she only washed her hands with soap and water at the beginning and at the end of the wound care treatment on Resident 484. On November 21, 2019, at 10:37 a.m., the Infection Control Preventionist (ICP) was interviewed. The ICP stated nursing staff should wash their hands with soap and water prior to performing wound care and in between performing wound care on different body sites. According to an article titled, "2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting," published by the CDC, dated July 2019, "...Perform hand hygiene...Before having direct contact with patients...After contact with blood fluids or excretions, mucous membranes, nonintact skin, or wound dressings...If hands will be moving from a contaminated-body site to a clean-body site during patient care...after removing gloves..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 43 of 44 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 11/21/2019 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 The facility policy and procedure titled, "Wound Care," revised October 2010, was reviewed. The policy indicated, "...Wash and dry hands thoroughly...Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites...Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly...Remove the disposable cloth next to the resident and discard into the designated container...Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C1PG11 Facility ID: CA240000045 If continuation sheet 44 of 44