Health inspection·February 7, 2024

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 7, 2024, at 1:49 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated that the facility had a log with the residents listed on it. The RN stated that one nurse was responsible for getting consent for the COVID vaccine from the RP. The RN stated that the nurse would document who gave consent or refused and the date of consent or refusal. The RN stated on December 27, 2023, she called the physician for a telephone order for the COVID vaccine for Resident 1. The RN stated it was another nurse ' s responsibility to decide on which three residents would get the vaccine. The RN stated that the following day she was reviewing the log and noticed that Resident 1 ' s RP refused the vaccine. The RN stated that the process was very confusing. A record review of the facility ' s document titled COVID Vaccinations Station 1 indicated .Room (number), (Resident 1 ' s name) .hand written note (RP) Refused (12/05) .Dose Completed Date .hand written note, 12/28/23 R (right) deltoid . A review of Resident 1's Orders dated December 27, 2023, at 3:51 p.m., indicated Communication Method: Phone .Comirnaty Intramuscular Suspension 30 MCG/0.3ML (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine) Inject 0.3 ml intramuscularly one time only for COVID vaccination for 7 Days Consent received from RP and verified by MD; risks and benefits of explained. Administer once available from the pharmacy . A review of Resident 1 ' s Progress Notes dated December 28, 2023, at 5 p.m., indicated (FM) came for visit and said not to give any shits (sic) (flu and covid vaccines) as per RP (responsible party), Endorsed to incoming shift. A review of Resident 1's Medication Administration Record dated December 2023, indicated .ComirnatyIntramuscular Suspension 30 MCG (micrograms)/0.3ML (milliliters) (COVID-19 (SARS- CoV-2) mRNA Virus Vaccine) Inject 0.3 ml Intramuscularly one time only for COVID vaccination for 7 Days Consent received from RP and verified by MD; risks and benefits of explained. Administer once available from the pharmacy. -Start Date- 12/27/2023 1551 (3:51 p.m.) . Vaccine was documented as given on December 28, 2023, at 11:06 p.m., in the right deltoid. A review of Resident 1's Progress Notes dated December 29, 2023, at 6:21 p.m., indicated Spoke with (Resident 1's) (FM) with (RP) on bedside, upset about the Covid vaccine given at night shift . A review of the facility's policy and procedure titled Pneumococcal, Influenza and COVID-19 Immunization Tracking and Monitoring revised February 2024, indicated .5) The patient resident or representative has the opportunity to accept or refuse the vaccine, and change their decision . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Regional Medical Center D/P Snf 730 Magnolia Avenue Corona, CA 92879 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an allegation of abuse, to the state survey agency, ombudsman, and local law enforcement, within two hours for one of three residents (Resident 1). This failure had the potential to result in the delay of investigation and implementation of corrective action for Resident 1. Findings: On February 1, 2024, at 9 a.m., a telephone interview was conducted with Resident 1's family member (FM). The FM stated that she was translating for the responsible party (RP). The FM stated that Resident 1 complained of pain in the back of his head approximately two weeks ago. The FM stated that Resident 1 made a fist and stated he was punched in the head. The FM was unaware if the facility staff knew about the allegation. On February 7, 2024, at 11:30 a.m., an unannounced visit to the facility for a complaint investigation was initiated. A review of Resident 1's medical records indicated he was admitted on [DATE], from a local general acute care facility with diagnoses of traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), right side subdural hematoma (bleeding between the brain and the skull), multiple fractures, deep vein thrombosis (DVT - refers to the formation of one or more blood clots in the veins), aspiration pneumonia (occurs when food or liquid is breathed into the lungs instead of swallows and causes an infection in the lungs), tracheostomy (a surgically created hole through the front of the neck and into the windpipe (trachea) and provides an air passage when the usual route for breathing is somehow obstructed or impaired), and perctaneous endoscopic gastrostomy (PEG - a feeding tube inserted through the skin and the stomach wall). On February 7, 2024, at 12:37 p.m., an interview was conducted with Resident 1. Resident 1 was asked if he had ever been physically abused by staff, Resident 1 answered yes. Resident 1 was asked how he was physically abused, Resident 1 stated I was hit in the head. Resident 1 was asked where he was hit, Resident 1 answered in the back of my head. Resident 1 was asked if he was hit with a closed fist or opened hand, Resident 1 responded closed. Resident 1 was asked when it happened. Resident 1 stated a couple of months ago. Resident 1 was asked what time of day the incident occurred, Resident 1 stated in the evening. Resident 1 was asked who hit him in the back of the head, Resident 1 stated (name of a staff member). Resident 1 was asked if the staff member said anything when he hit him in the back of the head. Resident 1 stated no. Resident 1 was asked if he told any of the staff about being hit in the back of the head, he stated Yes. Resident 1 was asked who was the staff member he told. Resident 1 stated I don 't know. Resident 1 was asked what the staff did, Resident 1 stated nothing. Resident 1 was asked if the staff member had taken care of him since the incident, Resident 1 stated no. Resident 1 was asked if he was evaluated by a nurse, or needed treatment for his head. Resident 1 stated head pain. Resident 1 was asked if he could say what the staff did for his head pain. Resident 1 shook his head to the left and right. Resident 1 was asked if the police came to take a statement. Resident 1 stated no. Resident 1 was asked if he was offered counseling. Resident 1 shook his head to the left and right. Resident 1 was asked if he felt safe at the facility. Resident 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corona Regional Medical Center D/P Snf 730 Magnolia Avenue Corona, CA 92879 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 stated I don ' t know. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Progress Notes dated October 15, 2023, at 8:12 p.m., indicated .accusing staff of threatening or hitting him Q, (every), shift no episode . Residents Affected - Few A review of Resident 1's Progress Notes dated November 2, 2023, at 7:58 a.m., indicated .Monitor for episodes of fabricating story, accusing staff of threatening or hitting him Q shift, no episode noted . On February 7, 2024, at 2:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated he was the abuse coordinator. The DON denied that Resident 1 informed him that he was threatened or hit by staff and denied that staff had informed him that Resident 1 was threatened or hit. The DON stated the incident should have been reported to the state survey agency and investigated. The DON confirmed that there was a Certified Nursing Assistant named (name of staff member). The DON stated that the alleged staff member was currently out of the country for a month. On February 7, 2024, at 2:52 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that she recalled Resident 1 and recalled documenting on November 2, 2023, at 7:58 a.m. The LVN stated that Resident 1 had fabricated stories about being threatened and being hit by staff members. The LVN stated that she would always document that Resident 1 fabricated stories accusing staff of threatening and hitting him. The LVN stated she did not know if the allegation was fabricated or true and did not know what she should have done. A review of the facility's staffing dated October 15, 2023, indicated the alleged staff member was on the schedule. A review of the facility's staffing dated November 2, 2023, indicated the alleged staff member was on the schedule. A review of the facility's policy and procedure titled Abuse Prevention revised April 2021, indicated .to be handled in a manner that prevents further abuse and promotes the health and welfare of all concerned individuals . I. REPORTING 1. Anyone who observes abusive/assaultive behavior or has reason to believe the behavior occurred is to immediately report the behavior to the Charge Nurse (or Clinical Nurse Manager). Failure to report the observed abuse may be interpreted to also be abuse. 2. The Charge Nurse or Clinical Nurse Manager must IMMEDIATELY contact the Abuse Prevention Coordinator .The Mandated Reporter, (an individual who holds a professional position that are required by law to report suspected or known instances of abuse to state agencies and local law enforcement), or the Director of Subacute /his or her designee i.e. RN Nurse Manager, RN Charge Nurse, Social Worker, etc. must notify the local law enforcement agency immediately no later than two (2) hours by telephone. A written report .must be submitted within two (2) hours to the local law enforcement agency, Licensing and Certification Office and Ombudsman . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 4 of 4