Health inspection·September 10, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 4, 5, and 6) had a comfortable and homelike environment for three days when the facility failed to ensure the air temperatures were safe and comfortable in nine of 20 resident rooms, according to the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021. This failure resulted in Residents 4, 5, and 6 being uncomfortable and had the potential to negatively affect residents' (in general) health and well-being. Findings: a. During a review of Resident 4's admission Record (AR) the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS, a chronic disease that affects the brain and spinal cord), quadriplegia (the condition in which both the arms and legs are paralyzed), and congestive heart failure (condition in which the heart cannot pump enough blood to all parts of the body). During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/27/2024, the MDS indicated Resident 4 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 4 was dependent on staff for toileting, dressing, and bathing. b. During a review of Resident 5's admission record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (when the lungs can't get enough oxygen into the blood), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and insomnia (persistent problems falling and staying asleep). During a review of Resident 5's MDS, dated 6/12/2024, the MDS indicated Resident 5 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 5 was dependent on staff for toileting and bathing. c. During a review of Resident 6's admission record, the admission record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), infection of amputation stump (after an amputation, the bit that's left beyond a healthy joint), and cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain). Page 1 of 3 055449 055449 09/10/2024 Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6's MDS, dated 8/7/2024, the MDS indicated Resident 6 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 6 required assistance from staff for toileting, bathing, and dressing. During an interview on 9/9/2024 at 2:18 p.m. with the Maintenance Supervisor (MS), the MS stated on Friday (9/6/2024), one of the Air Conditioner (AC) unit motors burned up (AC unit not working). The MS stated the AC technician arrived the same day to repair the AC unit. The MS stated rooms in Station 3 were the hottest rooms in the facility. The MS stated some of the facility staff complained about the air temperature being too hot in the facility. During a concurrent observation and interview on 9/9/2024 at 3:09 p.m. with the MS and Resident 4 in Room A, the MS used an infrared temperature gun (Temp-gun, device that measures temperatures) to measure the air temperature of Room A. The Temp-gun indicated the room temperature was 89 degrees Fahrenheit (F, unit of measurement). Resident 4 stated the room was too hot. Resident 4 stated Resident 4 had multiple sclerosis. Resident 4 stated hot temperatures could make Resident 4's MS flare up (also known as a relapse, when a person with MS experiences new or worsening symptoms). During a concurrent observation and interview on 9/9/2024 at 3:18 p.m. with the MS on the facility's roof, all 21 AC units were observed. The fan was not turning on the AC unit labeled 307-315. The MS stated the AC unit should be turning. The MS stated the AC unit was not working correctly. All other AC units on the roof had their fans running. During an interview on 9/9/2024 at 3:28 p.m. with the MS, the MS stated the facility had called the AC Technician (ACT) and that the ACT was on his way to the facility. The MS stated the MS thought another AC unit motor was broken. During a concurrent observation and interview on 9/9/2024 at 4:03 p.m. with the MS, all residents' (in general) room temperatures in Station 3 were checked. The MS used a Temp-gun to check the room temperatures. The Temp-gun indicated nine of the 20 rooms on the unit had temperatures higher than 81F. The temperatures of the nine rooms ranged from 83F - 89F. During a concurrent observation and interview on 9/9/2024 at 4:22 p.m. with the MS and Resident 5 in room B, the MS used a Temp-gun to measure the air temperature of Room B. The Temp-gun indicated the room temperature was 89 F. Resident 5 stated it had been hot at the facility for three days. Resident 5 stated Resident 5 felt weak on the previous day (9/8/2024). Resident 5 stated Resident 5 felt weak because of the heat. Resident 5 stated he wanted to stay in bed and keep his clothes off because it was too hot to get dressed. Resident 5 stated on Saturday (9/7/2024) Resident 5 wanted to paint but stayed in bed with his clothes off. During a concurrent observation and interview on 9/9/2024 at 4:25 p.m. with the MS and Resident 6 in room C, the MS used a Temp-gun to measure the air temperature of Room C. The Temp-gun indicated the room temperature was 84 F. Resident 6 stated Resident 6 felt warm. Resident 6 stated he felt uncomfortable. Resident 6 stated sometimes Resident 6 was sweaty due to the warm temperature in the facility. During an interview with ACT on 9/9/2024 at 4:55 p.m. with the ACT, the ACT stated he was at the facility to fix a different AC unit than the one the ACT fixed on Friday. During a review of the facility's revised P&P titled, Homelike Environment, revised February 2021, 055449 Page 2 of 3 055449 09/10/2024 Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723

F 0584 Level of Harm - Minimal harm or potential for actual harm the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment . The P&P indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . comfortable and safe temperatures of (71 °F - 8 I °F) . Residents Affected - Some 055449 Page 3 of 3