Chino Valley Health Care Cente

F-F609)

Findings:

During a telephone interview on 4/8/2025 at 1:38 p.m. with CNA 1, CNA 1 stated CNA 1 did not remember if CNA 1 received training from the facility regarding abuse prevention. CNA 1 stated CNA 1 did not know who

the facility's Abuse Coordinator was. CNA 1 stated CNA 1 did not know the facility had such a position.

During a telephone interview on 4/8/2025 at 3:47 p.m. with Registered Nurse (RN) 1, RN 1 stated incorrectly

the facility had 24 hours to report allegations of abuse against residents (in general). RN 1 stated RN 1 did not know what agencies the facility was required to report allegations of abuse to. RN 1 stated RN 1 did not know how to report allegations of abuse against residents (in general).

During a follow up telephone interview on 4/9/2025 at 11:22 p.m. with RN 1, RN 1 stated RN 1 would not report an allegation of abuse against a resident (in general) until RN 1 investigated the allegation and confirm

the abuse did happen.

During an interview on 4/9/2025 at 12:15 p.m. with the Director of Staff Development (DSD), the DSD stated all allegations of abuse must be reported to the Department, the Ombudsman, and to the local law enforcement, within two hours.

During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 055126 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055126 B. Wing 04/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766

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 0943 During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised March 2023, the P&P indicated, All reports of resident abuse (including injuries of Level of Harm - Minimal harm or unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, potential for actual harm state and federal agencies (as required by current regulations) . The P&P indicated allegations of abuse were to be reported within two hours. The P&P indicated, The administrator or the individual making the Residents Affected - Few allegation immediately reports his or her suspicion to the following persons or agencies:

a. The state licensing/certification agency responsible for surveying/licensing the facility.

b. The local/state ombudsman.

b. The resident's representative.

c. Law enforcement officials .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 055126