Health inspection·February 15, 2024

F 0656 initiated on January 11, 2024, indicated, .Monitor for and document any edema . Level of Harm - Minimal harm or potential for actual harm The wound care note for skin assessment dated [DATE], at 5:43 p.m., was reviewed. Residents Affected - Few The note indicated, Resident 161 had . bilateral upper extremities edema, elevated with pillows, Swelling to bilateral feet, elevated with pillows, charge nurse also made aware of skin concerns, continue with ongoing Tx (treatment) and on going plan of care . The nurse's progress notes from February 9, 2024, at 7:37 p.m., to February 13, 2024, at 7:39 a.m., was reviewed. There was no documented evidence Resident 161's edema was assessed by licensed staff during the 12 hour shift. CM 1 acknowledged there was no assessment in the nurse's notes of Resident 161's edema from February 9, 2024, to February 13, 2024. She stated licensed staff should have assessed and monitored Resident 161's edema. On February 14, 2024, at 4:45 p.m., a concurrent interview and record review was conducted with the Director of Subacute (DS). The DS acknowledged there was no monitoring of Resident 161's bilateral upper extremities and feet edema. On February 15, 2024, at 10 a.m., a concurrent record review and interview was conducted with CM 1 and the DS. Both acknowledged the care plan initiated on January 11, 2024, was not implemented. The facility's policy and procedure titled, .Comprehensive Care Plan, dated May 2023, was reviewed. The policy indicated, .The comprehensive assessment is based on a thorough assessment .are on going .Incorporate the interventions to address the symptoms of the underlying problem identified .Incorporate risk factors associated with identified problems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 2 of 16 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 02/15/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the enteral formula (EF - a form of nutrition that is delivered into the stomach as a liquid) was labeled with the date and time for one of six residents (Resident 45) receiving enteral formula. This failure had the potential for Resident 45 to experience complications from the formula, such as nausea, diarrhea, or infection. Findings: On February 12, 2024, at 9:50 a.m., Resident 45 was observed in bed with enteral formula feeding being delivered via pump. The EF container was observed with a blank label (no date and time of when it was hung.) On February 12, 2024, at 11:03 a.m., a concurrent observation and interview with Registered Nurse (RN) 1 was conducted. RN 1 observed Resident 45's EF container and stated the formula should be labeled and dated with the time once opened. RN 1 stated there was no way to tell when the EF was hung. RN 1 stated the risk of not dating the EF was that the resident could get an upset stomach, have diarrhea and abdominal pain. RN 1 stated the facility has apolicy on dating and timing the enteral formula feeding. On February 12, 2024, at 11:22 a.m., during a concurrent observation and interview with the unit Charge Nurse, Registered Nurse (RN) 2, RN 2 stated We write the date because it can only be hung for a 24-hour period. RN 2 further stated the risk of not labeling is one would not know how long the EF had been there and the patient can have GI (gastrointestinal) distress, nausea, vomiting, potentially abdominal pain and could increase the residents risk for infection. RN 2 further stated that many of their patients are on respirators and immunocompromised (having an impaired immune system), so they are more susceptible. On February 15, 2024, at 8:32 a.m., an interview was conducted with the Director of Subacute (DS). The DS stated nursing staff have to label and date the bags before they are hung and connected to the patient. If it is not dated, it is difficult to determine how long it's been hanging there. The DS stated the risk associated with not labeling the enteral feeding container is the patient could have abdominal issues gastrointestinal problems such as diarrhea and nausea. Resident 45's record was reviewed. Resident 45 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing.) Resident 45's physician orders dated November 4, 2023, indicated, .Glucerna (a brand of enteral formula) 50 ml (milliliters - unit of measurement)/hr. (hour) . A review of the facility policy titled, Enteral Formula (revised date March 2015), indicated, .Label feeding set with start time, date and nurses initial . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 3 of 16 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 02/15/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, staff interviews, and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time Registered Dietitian and/or a full-time Director of Food Services in accordance with California Code, Health and Safety Code - HSC § 1265.4 The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in inadequate supervision leading to food borne illness for seven residents who received food from the kitchen out of a facility census of 58. Findings: During the Federal re-certification survey from February 12, 2024 - February 15, 2024, it was noted that Food and Nutrition services provided meals not only to skilled nursing residents but also to a separately licensed, Behavioral unit. The skilled nursing facility's Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS) were working in 3 different facilities, Acute Hospital, Skilled Nursing facility (SNF) and Behavioral unit. Review of the organizational structure of the facility identified that the Skilled Nursing Facility was part of a continuing care of the Acute Hospital care. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. On February 12, 2024, at 9:56 a.m., an interview was conducted with the DRD and the DSS. The DRD and the DSS stated both of them were in charge as Food service/dietetic services supervisors with the Acute Hospital, Skilled Nursing Facility and Behavioral unit. On February 14, 2024, at 10:17 a.m., a phone interview was conducted with the Registered Dietician (RD) 3 and RD 4. RD 3 and RD 4 stated both of them worked as part time clinical dietitian two days per week at the SNF. RD 3 and RD 4 claimed they never involved any Food service/dietetic services work at the SNF. On February 14, 2024, at 10:36 a.m., an interview was conducted with RD 2. RD 2 stated she worked as a full time clinical dietitian at the SNF. RD 2 explained her main focus work loads were providing residents' nutrition assessment, evaluating Residents' with weight issue and developing residents' nutritional care plans. RD 2 stated she did not have experience of food service management work. RD 2 stated the Food service/dietetic services work at the SNF she perform were less than an hour test tray one time per month and less than an hour sanitation kitchen audit one time per month. On February 15, 2024, at 12:55 p.m., an interview was conducted with the Chief Operating Officer (COO). The COO confirmed the DRD and the DSS were the supervisors of Food and Nutrition Services which included the Acute Hospital, Skilled Nursing Facility and behavioral unit. During a review of the facility provided organizational chart, undated, indicated, Acute hospital and SNF organizational chart which showed the organization of Food and Nutrition Staff, reported to Chief Operating Officer and all Food and Nutrition staff were under the Director of Nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 4 of 16 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 02/15/2024 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 0801 Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 5 of 16 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 02/15/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: Residents Affected - Some 1. The Director of Nutritional Services and the Nutritional Service Manager did not instruct food service workers to follow manufacturer guideline for monitor temperature on dish machine. 2. The cook used wrong scoop plated lunch meal on February 13, 2024, for four residents (Residents 2, 19, 30, and 54). (Cross reference 803) These failures had the potential for unsafe food practices which may lead to foodborne illness (stomach illness acquired from ingesting contaminated food), and the potential to not meet the nutritional needs of the residents in a medically vulnerable population of seven out of 58 sample residents who received food prepared in the kitchen. 1. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Annex 3: Section 4-204.115 Warewashing Machines, Temperature Measuring Devices, the FDA Food Code indicated, The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Annex 3: Section 4-204.113 Warewashing Machine, Data Plate Operating Specifications, the FDA Food Code indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested, and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. On February 13, 2024, at 10:47 a.m., a concurrent observation, and record review of the high temperature dish machine was conducted. Observed the high temperature dish machine power wash temperature from gauge was 140 degrees Fahrenheit (°F - a unit of measurement) while doing dishes. Reviewed the manufacturer's guideline data plate for First tank power scrapper temperature on dish machine indicated Important keep temperature (temp) between 110 °F to 140 °F ; Second tank data plate for power wash temperature on dish machine indicated Important keep temp between 150 °F to 165 °F and third tank date plate for Final rinse temp on dish machine indicated, Important keep temp between 180 °F to 195 °F. Reviewed February 1-14, 2024, Dish machine temp log, there was no monitoring for power scrapper temperature. On February 14, 2024, at 10:05 a.m., an interview was conducted with the Dish machine Service Vendor (SCV). The SCV stated the dish machine need to stay in the manufacture recommended guideline temperature for properly sanitize the dishes. On February 14, 2024, at 4:00 p.m., an interview was conducted with the Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS). The DRD and the DSS stated they only focused on the dish machine final rinse temperature need to be over 180 °F and the dish machine test (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 6 of 16 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 02/15/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some strip turned orange color for properly sanitizing the dishes. The DRD and the DSS stated they did not concern about First tank power scrapper temperature and Second tank power wash temperature. Reviewed the manufacturer's guideline data plate for power wash temperature on dish machine indicated Important keep temp between 150 °F to 165 °F. Review of the facility's Dish Machine Temperature log, Eleven out of 14 days power wash temperature were out of range during February 2024. The facility's Dish Machine temperature log during February, 2024 indicated, Power wash temperature: 2/1/24: Breakfast (B): 189 °F, Dinner (D):138 °F; 2/3/24: B: 169 °F, Dinner (D):173 °F, 2/4/24: D:175 °F, 2/5/24: D: 167 °F, 2/6/24: B:181 °F, D: 138 °F, 2/7/24: B:172 °F, 2/8/24: B: 189 °F, L: 139 °F, D:140 °F, 2/10/24: B: 187 °F, L:172 °F, D: 189 °F , 2/11/24: B: 187 °F, L: 146 °F, D: 138 °F, 2/12/24: B:190 °F, 2/14: D: 174 °F 2. On February 13, 2024, at 11:53 a.m., a concurrent observation, interview, and menu review was conducted during lunch meal plating with the [NAME] (CK). The CK used a green scoop, 2.5 ounce (oz.- a unit of measure), for broccoli and rice instead of a grey scoop, four oz. per the menu for regular diet, No Concentrated Sweets diet and Low Sodium diet. Confirmed green scoop size with the CK, the CK stated green scoop was 2.5 oz. On February 13, 2024, at 2:30 p.m., an interview was conducted with the Director of Nutritional Services (DRD) and the Clinical Nutritional Manager (RD 1). The DRD and the RD1 were asked to explain the scoop colors and the size. They explained the green scoop was 2.5 oz. and the grey scoop was four oz. or equal to 1/2 cup. RD1 and DRD explained that if the wrong scoop size was used to plate the food for the residents, the residents would not get enough nutrition which could result in weight loss. During a review of the facility's Policy and Procedure titled, Portion Control Guidelines, revision date: 2/2024, indicated . Food Service Employees refers to production sheets for the proper portion size for all food service . When the patient/resident's menu has measured portions designated, food items may be measured by weight as appropriate . During a review of the facility's policy and Procedure titled, Menu Policy, review dated September 2022, indicated, .Standard recipes and standard serving guide are tools used by the food service staff to ensure nutritional adequacy is met for the patients/residents prescribed diet order . During a review of the job decription titled, COOK-DIETARY, undated, indicated, .POSITION SPECIFIC STANDARDS .1. Prepares all food items specified on daily production records in quantities indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 7 of 16 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 02/15/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of five residents (Residents 2, 19, 30, and 54), was met for lunch, when the meal was not plated in accordance with menu guidance for lunch. This failure had the potential to result in under or over nutrition. When a resident receives foods that are not consistent with their physician ordered diet, it may result in further compromising the resident's medical status. Findings: During an observation of the lunch meal plating on February 13, 2024, at 11:53 a.m., the [NAME] (CK) used a green scoop, 2.5 ounce (oz.- a unit of measure), for broccoli and rice instead of a grey scoop, 4 oz. per the menu and diet orders. During an interview on February 13, 2024, at 2:30 p.m., with Nutritional Service Supervisor (DSS) and Director of Nutritional Services (DRD), were asked to explain the scoop colors and the size. They explained the green scoop is 2.5 oz. and the grey scoop is four oz. or equal to 1/2 cup. DSS and DRD explained that if the wrong scoop size was used to plate the food the residents would not get enough nutrition, which could result in weight loss. A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 2 indicated, No concentrated sweets . A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 19 indicated, Sodium Restriction 2.4 GM (gram- a unit of measurement) . A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 30 indicated, Regular . A review of the facility's document titled, Order Sheet-Diet, dated January 22, 2024, for Resident 54 indicated, .No concentrated sweets . A review of the facility Policy and Procedure titled, Portion Control Guidelines, indicated . Food Service Employees refers to production sheets for the proper portion size for all food service . When the patient/resident's menu has measured portions designated, food items may be measured by weight as appropriate . A review of the facility's menus for Regular, Low Sodium, and No Concentrated Sweets diets, indicated .portion size for these diets was half cup of rice and half cup of broccoli . During a review of the facility's policy titled, Menu Policy, dated September 2022, indicated, .Standard recipes and standard serving guide are tools used by the food service staff to ensure nutritional adequacy is met for the patients/residents prescribed diet order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 8 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when : 1. The Prep sink did not have an air gap; 2. Nine cutting boards surface were heavily marred; 3. Three storage silver shelves in trayline area had rust; 4. Two microwaves in the kitchen were dirty; 5. Lacked temperature monitor for Prep table refrigerator; 6. Multiple areas in the kitchen were covered with dust; 7. The walk in refrigerator's gasket was wore out; 8. Unsanitary storage condition in walk in refrigerator; 9. Multiple areas in the kitchen's floor did not have smooth surface; 10. Trash were found in the multiple areas in the kitchen; 11. Build up grease and black/brown debris found on fire suppression unit above stove and fryer; 12. Cobweb found in dry storage room; and 13. Under the grill/stove range there was burn buildup material and black particles. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of seven out of 58 residents who received food prepared in the kitchen. Findings: 1. On February 12, 2024, at 10:45 a.m., an observation with the [NAME] (CK) in front of the Prep sink (sink used for washed produce). The CK used the prep sink to wash produce. On February 12, 2024, at 11:45 a.m., a concurrent observation and interview with the Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS) in front of the Prep sink was conducted. The DRD and the DSS stated they used this sink as the Prep sink. The DSS confirmed the Prep sink did not have an air gap (An air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food). The DRD was not aware the Prep sink need to have an air gap. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 9 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD, the DRD stated there was no policy and procedure for an air gap. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Section 5-203.14 Backflow Prevention Device, the FDA Food Code indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap . 2. On February 12, 2024, at 11:57 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the kitchen. There was four 24 inch length x 18 inch width cutting boards and another five 12 inch length x 18 inch width cutting boards were observed heavily marred (impaired surface). Some of the cutting boards had black and brown stain on surface. The DRD and the DSS confirmed the nine cutting boards were heavily marred. The DRD explained heavily marred cutting boards were unable to clean properly due to food particles stuck on scratched surface which could cause cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .13. Equipment/Environment: .iv. For cutting boards: .(d) Replace cutting board when deep grooves or gouges are visible on the board. 3. On February 12, 2024, at 9:59 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the kitchen trayline area. Three silver storage shelves were observed with brown grime. The DRD stated brown grime was rust on the silver storage shelves. The DRD stated storage shelves were not supposed to have rust because rust could get into foods stored on the shelves. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure for rusting shelves. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Section 4-101.11 Equipment Characteristics, the FDA Food Code indicated, .FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; . (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. 4. On February 12, 2024, at 9:53 a.m., a concurrent observation and interview was conducted with the DRD in the kitchen trayline area. Brownish particles were found inside the microwave and the microwave's door. The DRD stated the brownish particles inside the microwave and the microwave's door were splashed of the foods. On February 12, 2024, at 10:54 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the main cook area. The brownish particles were found inside the microwave. The DSS confirmed the brownish particles inside microwave were splashed of the foods. The DRD stated both microwaves needed to be clean after each used to prevent cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 10 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .13. Equipment/Environment: .equipment and contact surfaces are cleaned and sanitized between uses. 5. On February 13, 2024, at 10:01 a.m., a concurrent observation, interview and record review was conducted with the DRD, and the [NAME] in the kitchen main cook area. There was no temperature monitoring for the Prep table refrigerator in front of walk-in refrigerator which had foods stored inside. The [NAME] stated she did not monitor the Prep table refrigerator in front of the walk in refrigerator because the other side of the Prep table refrigerator in front of oven was broken. The DRD stated the [NAME] should monitor the Prep table refrigerator in front of the walk in refrigerator. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .10. Storage: .vi. Temperature records are maintained daily on refrigerators . During a review of the facility provided documentation, titled, Daily Record of Refrigerator/Freezer Temperature, indicated Prep table refrigerator was not monitored since September 8, 2023. 6. On February 12, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with the DRD in kitchen trayline area. There was black debris hanging on the vent near the enter door. Opened boxes of food were observed stored under the vent. The DRD stated the black debris was dust, which could potentially fall into the foods stored under the vent. On February 12, 2024, at 3:13 p.m., a concurrent observation and interview was conducted with the DRD and the DSS in kitchen. There was black/brown debris hanging on the wall above hand washing sink, the vent in cook area, all light fixtures, fire sprinklers, the wall behind ice machine. The DRD confirmed black/brown debris was dust. The DRD stated the dust could potentially fall into foods and cause cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I.SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized; . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the FDA Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 7. On February 12, 2024, at 4:28 p.m., a concurrent observation and interview was conducted with the DRD in the walk-in refrigerator. The gasket (rubber piece that lined around refrigerator door to prevent moist coming in refrigerator and cool air sip out refrigerator) on the walk-in refrigerator was observed to be worn out. The DRD explained worn out gasket was unable to prevent moist air from going into the walk-in refrigerator which could cause mold. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure for Nutritional Services Department regarding Equipment maintenance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 11 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Annex 3 Section: 4-501.11 Good Repair and Proper Adjustment, the Food code indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Residents Affected - Some 8. On February 12, 2024, at 10:39 a.m., an observation was conducted in the walk-in refrigerator. There was five food storage shelves inside the walk-in refrigerator. All five storage shelves were used to store produce, milk, eggs, and meats. The five storage shelves were observed covered with black/brown grime. Grayish/black, whitish fuzzy particles were found underneath of storage shelves. The wall was observed chipped and missing white paint. The white wall was observed with the black grime. The white pipe on ceiling behind the vent was covered with black debris. The floor under storage shelves had black grime. One orange, one yellow bell pepper, and one plastic bag were observed on the floor under the storage shelves. On February 12, 2024, at 4:28 p.m., an interview was conducted with the DRD and the DSS in the walk-in refrigerator. The DRD stated the grayish/black, whitish fuzzy particles underneath the storage shelves were mold. The DSS stated the food service workers were supposed to clean the storage shelves twice per week when they bring in new produce. The DRD stated the food service workers only wiped the top of the storage shelves and not underneath the shelves. The DRD also stated food service workers did not swept the floor under the storage shelves. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.III. POLICY; Efforts are directed toward assuring that cross-contamination is minimized; .and employee conduct is such as to contain infection or minimize the exposure to recognized hazards.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas.13. Equipment/Environment: .equipment and contact surfaces are cleaned and sanitized . 9. On February 12, 2024, at 4:49 p.m., a concurrent observation and interview was conducted with the DRD in the walk-in refrigerator. Multiple indentations on the floor was observed in the walk-in refrigerator where milks were stored. Whitish color liquid was observed sitting on the indentations of the floor. The DRD acknowledged the walk-refrigerator floor had multiple indentations. On February 13, 2024, at 10:41 a.m., a concurrent observation and interview was conducted with the DRD in front of the ice machine. The floor on the ice machine area was observed with rough surface with black grime. The DRD stated the floor did not have smooth surface and could not be cleaned properly. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure related to the floor surface. During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 6-101.11 Surface Characteristics, the Food Code indicated, (A) .materials for indoor floor, under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; . 10. On February 12, 2024, at 10:26 a.m., a concurrent observation and interview was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 12 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm the DSS in trayline area. Trash [one 4 ounces (oz- a unit of measurement) disposable cup, an opened butter condiment, plastic wraps, one container of 4 oz unopened orange juice], dirt, black grime were observed under the number four reach-in refrigerator. The DSS confirmed there was trash under the number four reach-in refrigerator. The DSS stated the potential risk of having trash in kitchen could attract pests. Residents Affected - Some On February 12, 2024, at 10:49 a.m., a concurrent observation and interview was conducted with the DSS and the DRD in the utility room. An empty opened can soda and a bottle cap and black grime were observed on the floor. The DSS stated an empty opened can soda and cap were not supposed to be on the floor. The DRD confirmed the floor had black grime. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 11. On February 13, 2024, at 10:23 a.m., a concurrent observation and interview was conducted with the DRD and the DSS. The brown/black debris, build up grease was observed hanging on the fire suppression unit above the stove. The DRD and the DSS confirmed the brown/black debris was dust and the build up grease accumulated on fire suppression unit above the stove. The DRD stated there was a potential risk dust and grease could fall into foods when cooks preparing foods on the stove. On February 13, 2024, at 10:23 a.m., a concurrent observation and interview was conducted with the DRD and the DSS. The brown/black debris, build up grease was observed hanging on fire suppression unit above the fryer. The DRD and the DSS confirmed the brown/black debris was dust and the build up grease accumulated on fire suppression unit above the fryer. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I.SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas . 12. On February 13, 2024, at 9:53 a.m., a concurrent observation and interview was conducted with the DRD in the dry storage room. Cobweb was observed under the storage shelves. The DRD confirmed there was cobweb under the storage shelves. During a review of the facility Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .11. Pest Control: a. The objective is to maintain a sanitary environment, preventing contamination and transmission of disease by insects or rodents.f. Daily, Managers and supervisors inspect all areas where food is stored, prepared, and served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 13 of 16 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 02/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm 13. On February 13, 2024, at 10:29 a.m., an interview was conducted with the DRD and the DSS in front of grill/stove range. There was burn buildup material and black particles under the grill. The DRD and the DSS confirmed there was burn buildup material and black particles under the grill. The DRD stated the burn buildup material and black particles was not supposed to be accumulated under the grill because it could cause cross contamination and could also attracted insects or pests. Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized.and employee conduct is such as to contain infection or minimize the exposure to recognized hazards. 12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas.13. Equipment/Environment: .equipment . are cleaned . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 14 of 16 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 02/15/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when trash was found on the ground surrounding the trash compactor, and the trash was piled up above the fill rim of the trash compactor. Residents Affected - Some This failure had the potential to attract rodents and insects which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food). Findings: During an observation and interview of Foodservice Worker (FSW), on February 13, 2024, at 2:00 p.m., the FSW was observed taking trash to the trash compactor located in the parking lot at the back of the facility. Bags of trash were seen above the trash compactor fill line, and loose trash (gloves, glass bottles, paper) on the ground around the compactor. One clear, plastic trash bag was hanging over the side of the trash compactor with a yellow liquid in it. There was a strong odor around the compactor. The FSW stated whoever emptied the trash before, should have completed the process by using the compactor to push the bags seen above the rim of the compactor into the dumpster. The FSW stated the trash on the ground is also supposed to be cleaned up and there should be nothing hanging over the sides of the trash compactor. He further stated the reason for compacting the trash into the dumpster was to prevent pests from being attracted to the smell. During an observation with concurrent interview on February 13, 2024, at 2:41 p.m., with the Director of Nutrition Services (DRD) and the Environmental Services (EVS) Supervisor, the DRD stated trash bags are not supposed to be left outside the compactor because it will attract pests. EVS was supposed to keep the area around the trash compactor clean. The EVS Supervisor also stated trash was not supposed to be on the ground surrounding the compactor area and trash should be pushed into the dumpster and not be left exposed because of the risk of infection from unwanted pests. A review of the facility's policy titled EVS- Trash Compactor and Area last reviewed September 2019, indicated, .Compactor area is cleaned daily of debris and washed weekly with cleaning solution and steam . A review of Food and Drug Administration (FDA) guidelines titled FDA Food Code 2022, dated January 18, 2023, indicated in 5-501.15(B), Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 15 of 16 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 02/15/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control prevention when Registered Nurse (RN) 3 did not wear gloves while handling a gastrostomy tube (G-tube - a tube inserted into the stomach to provide nutrition) for one resident (Resident 38). Residents Affected - Few This failure had the potential to expose the vulnerable resident to infection. Findings: On February 14, 2024, at 11:31 a.m., Resident 38 was observed in bed. Resident 38 had a G-tube for nutrition and was receiving her medications via G-tube. On February 14, 2024, at 11:31 a.m., during the medication administration observation, RN 3 was observed handling the G-tube of Resident 38 without gloves. On February 14, 2024, at 12:30 p.m., an interview was conducted with RN 3. RN 3 confirmed she did not wear gloves when handling Resident 38's G-tube. RN 3 stated she should have worn gloves while handling Resident 38's G-tube. On February 14, 2024, at 12:30 p.m., a concurrent interview with the clinical manager (CM) 1 was conducted. CM 1 stated RN 3 should have worn gloves when handling Resident 38's G-tube. Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and encounter for attention to gastrostomy. The physician's orders, dated November 16, 2023, indicated, .May administer meds and flush tube via slow push . Resident 38's care plan, initiated on November 16, 2023, indicated, .Potential for infection on feeding tube site .Will be free from signs and symptoms of infection on feeding tube site . The facility policy and procedure titled, Hand Hygiene Program, reviewed June 2023, was reviewed. The policy indicated, .Glove use .Gloves should be worn according to standard and contact precautions or when there is anticipated hand contact with blood, body fluids, secretions, excretions or mucous membranes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555390 If continuation sheet Page 16 of 16