Chino Valley Health Care Cente

F-F600

Findings:

During a review of Resident 23's Admission Record (AR), the AR indicated the facility admitted Resident 23

on 8/26/2020, and readmitted the resident on 9/21/2024, with diagnoses including impulse disorder (a group of behavioral conditions that make it difficult to control your actions or reactions), dementia (a progressive state of decline in mental abilities), and unspecified mood disorder (a mental health condition that causes significant and persistent changes in a person's emotional state, energy levels, and behavior).

During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025,

the MDS indicated Resident 23's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance with mobility.

During a review of Resident 47's AR, the AR indicated the facility admitted Resident 47 on 5/21/2024, and readmitted the resident on 10/9/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), restlessness and agitation, and anxiety disorder (mental health conditions characterized by excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life).

During a review of Resident 47's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/17/2025, the MDS indicated Resident 47's cognition was moderately impaired. The MDS indicated Resident 47 required partial/moderate assistance (helper does less than half the effort) with ADLs and required partial/moderate assistance with mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0609 During an observation on 4/29/2025 at 12:07 PM, there was loud yelling heard from the Northwest side of the facility. Certified Nursing Assistant (CNA) 8 was wheeling Resident 47 from the Northwest area through the Level of Harm - Minimal harm or Northeast corridor. Resident 47 appeared visibly scared and emotionally distressed. Resident 47's body was potential for actual harm tense and Resident 47 clutched the armrest of her wheelchair. Resident 47 stated, I'm scared. Resident 23 was standing in the doorway of room [ROOM NUMBER] and appeared angry; Resident 23's face was red, Residents Affected - Few and his body language was tense. Resident 23 yelled, I want my fu**ing lunch tray! in a loud and angry tone. Resident 23 proceeded to direct a racial slur and profanity toward Resident 47, shouting, Get that fu**ing ni**er b**ch away from me!

During an interview on 4/30/2025 at 3:25 PM, with the Administrator (ADM), the ADM stated the ADM had not been made aware of any incident involving verbal abuse or an altercation between Resident 23 and Resident 47. The ADM stated the incident should have been reported immediately. The ADM stated, any time there was a situation involving racial slurs or verbal abuse, staff were expected to notify their supervisor right away, and the ADM should be informed as well. The ADM stated, the facility had maintained clear policies regarding resident-to-resident interactions involving inappropriate, offensive, or abusive language.

The ADM stated the facility took such behaviors seriously. The ADM stated had the ADM been made aware of the incident at the time it occurred, the ADM would have initiated the appropriate steps [to address the incident]. The ADM stated language of that nature was offensive, discriminatory, and emotionally harmful, and should have been addressed promptly and thoroughly [by following] the facility's internal protocols.

During an interview on 4/30/2025 at 4:06 PM, with the Director of Nursing (DON), the DON stated the DON had not been notified of any incident involving verbal abuse, racial slurs, or an altercation between Resident 23 and Resident 47. The DON stated staff were expected to notify their immediate supervisors, the DON, and the ADM immediately when any incident occurred that may be considered abuse, including verbal altercations or racial slurs. The DON stated timely reporting was essential so the facility could initiate an internal investigation and report to the state agency as required.

During a telephone interview on 5/1/2025 at 9:16 AM, with CNA 9, CNA 9 stated CNA 9 had not reported the incident as thoroughly as CNA 9 should have. CNA 9 recalled CNA 9 may have told the Infection Preventionist (IP) Nurse there was yelling, but CNA 9 did not explain exactly what was said. CNA 9 stated because of the severity of the language used-including the racial slur and the profanity-the incident should have been reported immediately to the DON or the ADM so an internal investigation could be initiated.

During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revision dated 9/2022, the P&P indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

The P&P indicated, reporting Allegations to the Administrator and Authorities included,

1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0609 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: Level of Harm - Minimal harm or potential for actual harm a. The state licensing/certification agency responsible for surveying/licensing the facility;

Residents Affected - Few b. The local/state ombudsman;

c. The resident's representative;

d. Adult protective services (where state law provides jurisdiction in long-term care);

e. Law enforcement officials;

f. The resident's attending physician; and

g. The facility medical director.

3. Immediately is defined as:

a. Within two hours of an allegation involving abuse or result in serious bodily injury; or

b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

5. Notices include, as appropriate:

a. The resident's name;

b. The resident's room number;

c. The type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.);

d. The date and time the alleged incident occurred;

e. The name(s) of all persons involved in the alleged incident; and

f. What immediate action was taken by the facility.

6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108 safety Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents Residents Affected - Few (Resident 3), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) did not elope from the facility's secured unit (specialized healthcare setting that restricts patient/resident movement and access to promote safety with measures such as locked doors and surveillance) on 4/24/2025, at 7: 06 PM by failing to ensure:

1. Certified Nursing Assistant (CNA) 6 closed/locked the door when CNA 6 exited the facility's secured unit and ascertained (make sure of) Resident 3 did not follow CNA 6 out of the secured unit.

2. Receptionist (RC) 1 clocked and set the alarm on the front door located in the facility's lobby to prevent Resident 3 from leaving the facility without supervision.

3. CNA 7 implemented Resident 3's Care Plan (CP) titled, Elopement Risk, indicating to monitor Resident 3 and to follow the facility's visual check protocol (to check the resident where about with the naked eyes) [Q (every) 15-minute monitoring].

These deficient practices resulted in Resident 3's elopement on 4/24/2025 at 7:06 PM, placing Resident 3 at risk for vehicular accidents due to the facility is located in a busy street with many cars driving by, negative outcome from not receiving Resident 3's medication, and exposure due to extreme temperatures (heat

during the day and cold during the night) that could lead to serious injury, serious harm, or death.

On 4/28/2025 at 5:20 PM, while onsite at the facility, the State Survey Agency (SSA) identified an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure the doors to the secured unit were closed after CNA 6 walked out of the secured unit, the front lobby's door was locked and alarmed, Resident 3 was monitored/checked every 15 minutes, and to prevent the elopement of Resident 3 on 4/24/2025.

On 4/29/2025 at 3:24 PM, while onsite at the facility, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ) for

the facility's failure to ensure Resident 3 did not elope from the facility on 4/24/2025 at 7:06 PM. The SSA verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and

record reviews, and determined the IJ situation regarding Resident 3's elopement due to lack of supervision, unlocked secured unit door, and no alarm on the front lobby door, were no longer present. The SSA removed

the IJ on 4/29/2025 at 5 PM in the presence of the ADM.

The acceptable IJRP included the following summarized actions:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 A. Immediate Corrective Actions:

Level of Harm - Immediate 1. On 4/24/2025, the DON provided a verbal one-on-one in-service (education given to one staff by one jeopardy to resident health or educator) via phone regarding the elopement policy to CNA 6, following a disciplinary Performance safety Correction on 4/25/2025.

Residents Affected - Few 2. On 4/25/2025, 4/26/2025, and 4/27/2025, the Registered Nurse Supervisor RNS 1 had contacted the nearby hospitals, and local police department to locate Resident 3. On 4/25/2025 the ADM contacted the private investigators (PI) who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.

3. On 4/28/2025, the local police found Resident 3 and dropped Resident 3 off at Clinic 1. at approximately 6:30 AM. The DON communicated with Clinic 1's Nurse (CN) 1 who confirmed Resident 3 was currently in Clinic 1 with stable (normal) vital signs (VS, measuring the basic functions of your body temperature, blood pressure, pulse, and respirations). The DON notified Resident 3's Primary Physician/Medical Doctor (MD 1) who instructed to transfer Resident 3 back to the facility.

4. On 4/28/2025, two CNA's (CNAs 1 and 2) picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility at 4:35 PM.

5. On 4/28/2025, RNS 1 conducted a comprehensive assessment of Resident 3 upon Resident 3's return to

the facility. Resident 3's VS were stable, no signs or symptoms of major injury were noted. MD 1 ordered to transfer Resident 3 to a General Acute Care Hospital (GACH) for further evaluation on 4/29/2025. Facility staff notified Resident 3's conservator regarding Resident 3 was found.

6. On 4/28/2025, the DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.

7. Effective 4/28/2025, the facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.

8. On 4/28/2025, and 4/29/2025, the DON and the Director of Staff Development (DSD) provided in-services to staff members regarding the elopement policy, covering the following topics:

a. Supervise and redirect residents who are close to the exits, to mitigate the risk of elopement.

b. While entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors.

c. The importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision.

d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.

e. Elopement Trainings is as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 e1. As of 4/29/2025, 7 out of 8 RNs, 14 of 14 Licensed Vocational Nurses (LVNs), 36 of 42 CNA's, 20 of 20 department managers and assistants, 4 of 4 activity assistants, 7 of 7 housekeeping and laundry employees, Level of Harm - Immediate 10 of 11 dietary service staff received the in-service training for elopement. jeopardy to resident health or safety e2. 8 staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Residents Affected - Few e3. 7 staff were not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.

e4. The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted

in developing the IJ removal plan.

9. On 4/29/2025, the facility also installed a new door keypad for safety in the front lobby.

B. Identification of other Residents:

1. On 4/28/2025, there were 48 residents residing in the secured unit.

2. On 4/28/2025 and 4/29/2025, the ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.

3. On 4/27/2025, 4/28/2025, and 4/29/2025. the maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.

C. Systematic Change:

1. Effective 4/29/2025, the DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics:

a. Supervise and redirect residents who are close to the exits, to mitigate the risk of elopement.

b. While entering or exiting the secured unit, staff members must check/confirm that no residents are exiting

the secured unit before walking away from the exit doors.

c. The importance of conducting rounds every 15 minutes and as needed for adequate supervision.

d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.

2. The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.

3. Effective 4/29/2025, the facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.

D. Monitoring Performance:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 1. The DON, the DSD or the RNS 1 would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log. Level of Harm - Immediate jeopardy to resident health or 2. The ADM and the DON developed a Quality Assurance and Performance Improvement (QAPI, data driven safety and a proactive approach to quality improvement) for elopement to address the deficient practice in the IJ findings. Residents Affected - Few Findings:

During a review of Resident 3's Admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted to the facility on [DATE REDACTED], with diagnoses that included paranoid (when a person feels distrustful and suspicious of other people) schizophrenia (a serious mental health condition that affects how people think, feel, and behave, characterized by prominent delusions [a belief or altered reality that is persistently held despite evidence or agreement to the contrary] and hallucinations [false perception of objects or events involving the senses]), anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), unspecified convulsions (a sudden, violent, irregular movement of a limb [arm or leg] or of the body), epilepsy [a disorder in which nerve cell activity in the brain is disturbed, causing seizures (a sudden burst of electrical activity in the brain)], cognitive communication deficit (difficulties with communication affecting the ability to understand), and diabetes mellitus (a disease that results in elevated levels of glucose in the blood).

During a review of Resident 3's CP, titled Elopement Risk, initiated 8/21/2023 (no revision date indicated),

the CP indicated Resident 3 sometimes left the facility without authorization/permission. The CP's interventions indicated for staff to continue to provide frequent visual checks (every 15 minutes) of Resident 3's where abouts (the place or general locality where a person is) in the secured unit, and to follow the protocol for visual checks (check the resident every 15 minutes).

During a review of Resident 3's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 8/30/2024, the COC indicated on 8/30/2024 at 8 AM, Resident 3 showed exit seeking behaviors and increased delusions that someone was waiting for Resident 3 outside of the facility. The COC indicated (on 8/30/2024) at 10 AM, Resident 3 was noted to be walking up and down the hallways looking hypervigilant (being excessively or abnormally alert to potential danger or threat), looking to get out [of the facility], screaming and shouting I need to get out of here now.

During a review of Resident 3's Physician Orders (POs) for the month of September 2024, the POs indicated

the following orders:

1. Admit Resident 3 to the secured unit, dated 9/9/2024.

2. Humalog Injection Solution [a rapid-acting insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) that starts working faster and works for a shorter period of time than regular/short-acting insulin] 100 unit milliliter (ml, unit of measurement) to inject as per sliding scale (a scale followed, dose of insulin varies based on blood sugar levels), dated 9/20/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 3. Lantus Solostar [a long-acting (a type of insulin that works throughout the day and night to provide residents/patients with low levels of insulin all the time) man-made-insulin used to control high blood sugar] Level of Harm - Immediate subcutaneous (to administer medications between skin and muscle ) solution pen-injector inject (a device jeopardy to resident health or that provides a nonelectrically-powered, mechanically-operated method of accurately injecting safety medication/insulin) 100 unit/ml, administer 15 units at bedtime for diabetes mellitus with hyperglycemia (high blood sugar), check finger stick blood sugar (FSBS, a little poke is make in the finger, and a little teeny, tiny Residents Affected - Few drop of blood is withdrawn to test the blood sugar/glucose) before administration, dated 9/9/2024.

4. Tegretol (carbamazepine, medication used to treat seizures) tablet, 200 milligrams (mg, unit of measurement) administered by mouth, three times a day, dated 9/9/2024.

5. Zyprexa (Olanzapine, medication used to treat schizophrenia) tablet, 10 mg, give 1 tablet by mouth, one time a day, for paranoid schizophrenia manifested by delusion that a judge ordered Resident 3 to take the medication.

During a review of Resident 3's History and Physical (H&P), dated 9/10/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.

During a review of Resident 3's Elopement Risk Assessments ([NAME]), dated 9/26/2024, 12/24/2024 and 3/18/2025, the [NAME] indicated Resident 3 was assessed at risk for elopement due to Resident 3 wandered aimlessly (to move around or go to different places without having a particular purpose or direction), had verbally expressed the desire to go home, packed belongings to go home, and stayed near an exit door.

During a review of Resident 3's Minimum Data Set (MDS- a resident assessment and care screening tool), dated 3/18/2025, the MDS indicated Resident 3 had moderate impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 3 needed supervision (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity and may be provided throughout the activity or intermittently) with oral hygiene, toileting, and personal hygiene.

During a review of Resident 3's Police Report (PR), dated 4/24/2025, the PR indicated on 4/24/2025 at approximately 9:48 PM, Resident 3 was reported missing. The PR indicated (on 4/24/2025) at around 8 PM, facility staff looked through the entire facility and were unable to locate Resident 3. The PR indicated the facility's surveillance video footage captured Resident 3 walking in the [facility's] hallway (on 4/24/2025) at approximately 6 PM and at 7 PM, Resident 3 was seen standing by the secured unit's double doors. The PR indicated, A medical staff [CNA 6] opened the locked door and walked through the door. The PR indicated Resident 3 held the door open, walked behind CNA 6, then opened the front entrance door, and walked toward the north bound on [T Avenue, street located in front of the facility]. The PR indicated Resident 3 was diagnosed with several medical conditions, required constant medical attention, took prescribed medication, and was unable to care for herself. The PR indicated Resident 3 was a Critical missing person. The PR indicated Resident 3 left the health care facility without anyone [staff] noticing.

During an observation on 4/28/2025 at 10:37 AM of the facility's premises. There was double glass doors located at the front of the facility's lobby. The double doors were pushed open to exit the facility. Past the double doors, there was a busy street with multiple cars moving along the road.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 During a concurrent observation of the facility's surveillance video, dated 4/24/2025, time at 7:06 PM and

interview with the DON, on 4/28/2025 at 12:13 PM, the facility's surveillance video indicated Resident 3 Level of Harm - Immediate exited the facility on 4/24/2025, at 7:06 PM and walked toward the left side of the facility. The video indicated jeopardy to resident health or there were multiple cars driving by on the major street located in front of the facility. The DON stated, the safety facility's surveillance video dated 4/24/2025, timed at 7:06 PM, indicated Resident 3 was in the secured unit's hallway, standing next to the exit door. The DON stated, CNA 6 opened the facility's locked door and walked Residents Affected - Few out of the secured unit. The DON stated, Resident 3 placed Resident 3's hand between the double doors to prevent the doors from closing. The DON stated Resident 3 pushed the double doors open, walked into the facility's lobby, and walked out of the facility. The DON stated there were no staff visible past the secured unit door or in the facility's lobby. The DON stated Resident 3 walked out of the facility's main door, Like a visitor, and the facility located on a busy street with cars constantly driving by. The DON stated the facility's main lobby door was unlocked and no alarm or blinking lights were heard or observed visible in the surveillance video. The DON stated there should have been a staff member (receptionist) at the front desk monitoring who entered or left the facility. The DON stated the front doors should always be locked and the alarm should have turned on [sounded] to alert facility staff when people (staff, residents and or visitors) attempted to enter or exit the facility, as a safety measure to prevent residents (in general) from eloping.

During a concurrent observation of the facility's surveillance video, dated 4/24/2025, at 7:06 PM, and an

interview with the ADM on 4/28/2025 at 3:06 PM, the surveillance video indicated Resident 3 exited the facility on 4/24/2025, at 7:06 PM. The ADM stated, per the surveillance video, CNA 6 walked out of the facility's secured unit into the facility's lobby. The ADM stated Resident 3 walked behind CNA 6, pushed the lobby front doors open, walked out of the facility, and walked toward the busy street in front of the facility.

The ADM stated, according to the surveillance video, no staff were seen at the front desk on 4/24/2025, since 6:30 PM, and the facility's staff members were unaware of Resident 3's elopement (on 4/24/2025, at 7:06 PM).

During a review of Resident 3's 3 PM to 11 PM Resident Check (PMRC) log, dated 4/24/2025, completed by CNA 7, the PMRC log indicated Resident 3's where abouts were to be monitored by CNA 7 every 15 minutes. The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank (no indication of Resident 3's location).

During a review of Resident 3's PMRC log, dated 4/24/2025 and an interview with CNA 7, on 4/28/2025 at 3:33 PM, The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank. CNA 7 stated all residents resided in the secured unit (including Resident 3) were to be monitored/checked every 15 minutes. CNA 7 stated CNA 7 was supposed to monitor and document the time and location of each resident assigned to CNA 7. CNA 7 stated, on 4/24/2025, (from 3 pm to 11 pm shift) CNA 7 was the primary CNA assigned to care for Resident 3. CNA 7 stated CNA 7 documented Resident 3's where abouts as being in the hallway on 4/24/2025, at 6 PM, 6:15 PM, and at 6:30 PM. CNA 7 stated CNA 7 last saw Resident 3 (on 4/24/2025), at 6:30 PM just before the scheduled smoke break for the smokers (residents who smoke) which lasted until 7 PM. CNA 7 stated it was unrealistic to monitor (check and document the residents [all assigned residents including Resident 3'] location every 15 minutes because CNA 7 was busy assisting and providing care to other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0689 During an interview with the DSD, on 4/28/2025 at 3:43 PM, the DSD stated CNA 6 was in-serviced (educated) on the necessary safety steps to take when staff entered and exited the facility's secured units Level of Harm - Immediate (prior to Resident 3's elopement). The DSD stated, after exiting the secured unit, CNA 6 needed to ensure jeopardy to resident health or the secured door was closed shut and residents did not follow CNA 6 or attempted to exit the secured unit. safety The DSD stated, when these steps [closed the door and made sure residents did not leave the secured unit without supervision] were not taken, residents could elope from the facility and could walk onto the busy Residents Affected - Few street and get hurt.

During a telephone interview with CNA 6 on 4/28/2025 at 3:54 PM, CNA 6 stated, on 4/24/2025 at around 7 PM, CNA 6 unlocked the secured unit doors and exited the secured unit. CNA 6 stated CNA 6 did not check if the door closed shut behind CNA 6 upon exiting the secured unit or ensure there were no residents standing close to the doors. CNA 6 stated it was important to ensure the doors were closed shut and locked, upon exiting the secured unit, so the resident (Resident 3) did not elope.

During a review of Resident 3's PMRC log, dated 4/24/2025 and an interview with the DON on 4/29/2025 at 3:30 PM, The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank.

The DON stated Resident 3 was discovered missing on 4/24/2025, between 8:40 PM to 9 PM.

During an interview with LVN 4, on 4/29/2025 at 3:40 PM, LVN 4 stated, on 4/24/2025, LVN 4 was the person in charge of the secured unit. LVN 4 stated Resident 3 was observant, smart, and aware of Resident 3's surroundings. LVN 4 stated on 4/24/2025, at around 9 PM, CNA 6 informed LVN 4 Resident 3 was missing. LVN 4 stated the assigned CNA (CNA 6) was responsible for monitoring the whereabouts of Resident 3 every 15 minutes.

During a review of the facility's undated policy and procedures (P&P) titled, Missing Resident, the P&P indicated The facility's objective was to prevent possible injury or death to a resident and for wanderers (exit seeking residents) to be checked on a regular basis.

During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated Resident safety, supervision and assistance to prevent accidents are facility wide priorities. The P&P indicated systems approach to safety included, facility-oriented and resident-oriented approaches to safety are used together to implement a system's approach to safety, which considers the hazards identified

in the environment and individual resident risk factors. The P&P indicated to adjust interventions accordingly.

During a review of the facility's P&P titled, Wandering and Elopements, revised 3/2019, the P&P indicated

The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 055126

F-F609

Findings:

During a review of Resident 23's Admission Record (AR), the AR indicated the facility admitted Resident 23

on 8/26/2020, and readmitted the resident on 9/21/2024, with diagnoses including impulse disorder (a group of behavioral conditions that make it difficult to control your actions or reactions), dementia (a progressive state of decline in mental abilities), and unspecified mood disorder (a mental health condition that causes significant and persistent changes in a person's emotional state, energy levels, and behavior).

During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025,

the MDS indicated Resident 23's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance with mobility.

During a review of Resident 47's Admission Record (AR), the AR indicated the facility admitted Resident 47

on 5/21/2024, and readmitted the resident on 10/9/2024, with diagnoses including dementia, restlessness and agitation, and anxiety disorder (mental health conditions characterized by excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life).

During a review of Resident 47's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/17/2025, the MDS indicated Resident 47's cognition was moderately impaired. The MDS indicated Resident 47 required partial/moderate assistance (helper does less than half the effort) with ADLs and required partial/moderate assistance with mobility.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0600 During an observation on 4/29/2025 at 12:07 PM, while conducting routine investigative tasks, the surveyor was in the conference room located in the Northeast corridor of the facility. Loud yelling was heard that came Level of Harm - Minimal harm or from the Northwest side of the facility. Upon exiting the conference room to assess the source of the potential for actual harm disturbance, the surveyor observed Certified Nursing Assistant (CNA) 8 wheeling Resident 47 from the Northwest area through the Northeast corridor. Resident 47 appeared visibly scared and emotionally Residents Affected - Few distressed. Resident 47's body was tense and Resident 47 clutched the armrest of her wheelchair. Resident 47 audibly stated, I'm scared. Resident 23 was standing in the doorway of room [ROOM NUMBER] and appeared angry; Resident 23's face was red, and his body language was tense. Upon seeing the surveyor, Resident 23 immediately yelled, I want my fu**ing lunch tray! in a loud and angry tone. Resident 23 proceeded to direct a racial slur and profanity toward Resident 47, shouting, Get that fu**ing ni**er b**ch away from me! The language was overheard by Resident 47, CNA 9, and other residents (unidentified). CNA 9 immediately intervened and in a firm but calm voice, told Resident 23, You may not speak to other residents like that. That is not respectful!

During an interview on 4/30/2025 at 8:15 AM, with CNA 8, CNA 8 confirmed being on duty on 4/29/2025, the day of the incident involving Resident 23 and Resident 47. CNA 8 stated at approximately 12 PM, CNA 8 heard loud yelling coming from the Northwest area of the facility. CNA 8 stated CNA 8 observed Resident 23 and Resident 47 outside of room [ROOM NUMBER] (Resident 23's room). CNA 8 stated Resident 23 was angry, was yelling, and was demanding food and was red in the face. CNA 8 stated Resident 47 was in her wheelchair outside room [ROOM NUMBER] and Resident 47 appeared scared and distressed. CNA 8 stated Resident 47 was active in Resident 47's wheelchair, frequently took strolls down the hallway, and never caused trouble. CNA 8 stated CNA 8 had heard Resident 23 use racial slurs and obscenities in the past, sometimes directed toward staff or other residents. CNA 8 stated this [behavior] usually occurred when Resident 23 was frustrated, such as when he did not receive what he wanted right away, especially food or care. CNA 8 stated Resident 23 got loud, started yelling, and used curse words. CNA 8 stated the altercation between Resident 23 and Resident 47 could have been avoided if there had been more staff monitoring the hallway, especially around lunchtime. CNA 8 stated the facility was aware of Resident 23's behavior history, and lunchtime was a high-risk period for Resident 47, due to similar behavior being observed in the past. CNA 8 stated if staff had been nearby or had eyes on Resident 23, they might have been able to intervene

before the situation escalated.

During an interview on 4/30/2025 at 3:25 PM, with the Administrator (ADM), the ADM stated the facility had maintained clear policies regarding resident-to-resident interactions involving inappropriate, offensive, or abusive language. The ADM stated the facility took such behaviors seriously. The ADM stated had the ADM been made aware of the incident at the time it occurred, the ADM would have initiated the appropriate steps [to address the incident]. The ADM stated considering what had reportedly been said, the incident did indicate verbal abuse toward another resident. The ADM stated language of that nature was offensive, discriminatory, and emotionally harmful, and should have been addressed promptly and thoroughly [by following] the facility's internal protocols.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0600 During a telephone interview on 5/1/2025 at 9:16 AM, with CNA 9, CNA 9 stated CNA 9 was walking through

the Northwest corridor of the facility on 4/29/2025 around 12:00 PM. CNA 9 stated Resident 23 used both Level of Harm - Minimal harm or profanity and a racial slur directed at Resident 47. CNA 9 reported Resident 23 yelled, Get that ni**er b**ch potential for actual harm away from me. CNA 9 described the statement as loud, aggressive, and directed at Resident 47. CNA 9 stated CNA 9 told Resident 23 not to speak to Resident 47 in that way because it was not respectful. CNA 9 Residents Affected - Few stated CNA 9 attempted to calm Resident 23 and de-escalate the situation. CNA 9 stated CNA 9 reminded Resident 23 that his lunch tray was coming out shortly. CNA 9 stated using that kind of language constituted verbal abuse and emphasized that no one should be spoken to in that manner, especially not by another resident. CNA 9 stated Resident 47 did not deserve that treatment because Resident 47 was simply in the hallway and the incident clearly shook-up Resident 47.

During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revision dated 4/2021, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 055126 Department of Health & Human Services Printed: 08/27/2025 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 05/01/2025

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50016

Residents Affected - Few Based on observation, interview, and record review, the facility failed to report verbal abuse within two hours that involved one of one sampled resident (Resident 47) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating.

This deficient practice prevented timely investigation and implementation of appropriate measures, which could potentially allowed continued abuse to Resident 47.

Cross Reference