Health inspection·May 30, 2025

F 0689 Level of Harm - Actual harm During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. Residents Affected - Few During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. The COC form indicated the top of the Hoyer lift was caught by the shower gurney, and CNA 4's left arm was wedged between Resident 1 and the shower gurney in assist to the fall. The COC form indicated Resident 1's (right) leg was noted to be caught between the sides of the shower gurney. The COC form indicated Resident 1 had pain (pain level unrated) to Resident 1's right lower leg, bruising (skin discoloration from damaged, leaking blood vessels underneath the skin) to Resident 1's right lower leg and right finger (location unspecified), and lump (bump or a solid mass without a regular shape) on the back right side of Resident 1's head. The COC form indicated Nurse Practitioner (NP- a nurse with advanced clinical education and training) 1 was notified and ordered to transfer Resident 1 to GACH 1 for further evaluation. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. The EDNP indicated given Resident 1 being on blood thinners (medications that help prevent blood clots from forming), a comprehensive (a large scope; covering completely or broadly) workup was initiated for evaluation of possible brain bleed (bleeding within the skull, specifically the brain and its surrounding areas), fractures (a break or crack in a bone), spinal (backbone, the bone from the skull to the tailbone) injury, dislocation (a medical condition where the two bones forming a joint are no longer properly aligned), and neurovascular (involving both nerves and blood vessels) injury. The EDNP indicated Resident 1 was to be admitted to GACH 1's Trauma Intensive Care Unit (TICUspecialized unit within a hospital that provides critical care to patients with severe trauma injuries, requiring advanced monitoring) and started on Keppra (a medication used to treat certain types of seizures [a sudden burst of uncontrolled electrical activity in the brain]) intravenous (IV- soft, flexible tube inserted into a vein) drip (medical technique used to administer fluids, medication, or nutrients directly to the bloodstream). During a review of Resident 1's head CT Scan Report (CT Report), dated 5/26/2025, timed at 5:32 pm, the CT Report indicated there was no evidence of subarachnoid hemorrhage (SAH- serious condition where bleeding occurs in the space between the brain and the tissue covering it). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 2 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 review of Resident 1's GACH 1 EDNP Addendum dated 5/26/2025, timed at 6:44 pm, the EDNP Addendum indicated Resident 1 was cleared for discharge and was discharged in stable condition. Level of Harm - Actual harm Residents Affected - Few During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During a concurrent observation of Resident 1 inside Resident 1's room and interview on 5/29/2025 at 11:41 am with Licensed Vocational Nurse (LVN) 2, Resident 1 was lying on Resident 1's bed with noticeable injuries to Resident 1 right index (pointer) finger and right leg. LVN 2 stated Resident 1 had a bruise on the right index (pointer) finger and a bump on the back right side of Resident 1's head, near Resident 1's neck. LVN 2 stated Resident 1 had a raised bump on Resident 1's right shin that was approximately two (2) inches (in- unit of measurement) by one and a half (1.5) in with purple and yellowish tone around the bump's edges. LVN 2 stated Resident 1's (right) leg was swollen from the injury. LVN 2 stated the right outer side of Resident 1's foot was also bruised and slightly purple and greenish in color. During an interview on 5/29/2025 at 11:46 am with LVN 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated the facility was short-staffed on Station 3 (the station where Resident 1 resides) that day (5/26/2025). LVN 2 stated LVN 2 was two doors down from Resident 1's room when LVN 2 heard CNA 4 asking for help in Resident 1's room. LVN 2 stated when LVN 2 came into Resident 1's room, LVN 2 saw that the Hoyer lift was in between Resident 1's bed and Resident 1's roommate's bed, tilted over on its right side but was stopped by the shower gurney. LVN 2 stated LVN 2 found CNA 4 still assisting Resident 1 and trying to stop Resident 1 from falling by wedging CNA 4's left arm between Resident 1's right leg and the shower gurney. LVN 2 stated one of the bolts (a screw-like metal object without a point, used to fasten things together) on the Hoyer lift popped out. LVN 2 stated LVN 2 and other staff (unidentified) had to work to get the cuffs (the end part, usually thicker) off the sling to free Resident 1's (right) leg. LVN 2 stated after LVN 2 and other staff (unidentified) freed Resident 1's right leg, LVN 2 noticed Resident 1's right leg injury. LVN 2 stated Resident 1's right leg was instantly a goose egg (when blood collects between the skin and the muscle). LVN 2 stated less than 30 minutes after Resident 1 fell, Resident 1 complained of a bump on the back right side of Resident 1's head. LVN 2 stated the Treatment Nurse (TN) assessed Resident 1's head, while LVN 2 called 9-1-1 (phone number used to contact emergency services in the event of a medical emergency). During an interview with on 5/29/2025 at 1:14 pm with the TN, the TN stated on 5/26/2025 (unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 3 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 Level of Harm - Actual harm Residents Affected - Few remember exact time), Registered Nurse (RN) 2 asked the TN to assess Resident 1 after, an incident with the Hoyer lift. The TN stated Resident 1 had swelling to the right shin that was mildly red and had mild redness to the right index finger. The TN stated the TN assessed Resident 1's head but did not feel anything (without abnormal findings). The TN stated about 30 to 40 minutes after the assessment was completed, Resident 1 asked the TN to assess Resident 1's head again because Resident 1 told the TN, I think I hit my head. The TN stated the TN assessed Resident 1's head again and felt a bump to the back right side of Resident 1's head. The TN stated the TN notified NP 1 and NP 1 ordered to transfer Resident 1 to ER for further evaluation. The TN stated two staff needed to operate the Hoyer lift for safety issues because it was a mechanical lift. The TN stated if two staff were operating the lift, it was possible that the resident (Resident 1) may not have fallen or gotten hurt. During a concurrent record review and telephone interview on 5/29/2025 at 3:48 pm with the Director of Staff Development (DSD), the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025 was reviewed. The [NAME] indicated staff would Verbalize the understanding of facility policy requiring Two-Person Assist when using a (Hoyer) lift . Acknowledge that one-person lift will lead to suspension or possible termination. The [NAME] indicated CNA 4 signed the [NAME] to confirm CNA 4 attended the training dated 2/19/2025. The DSD stated CNA 4 needed to be operating the Hoyer lift with another staff member (two-person physical assistance) in case there was an issue with the Hoyer lift such as a malfunction. The DSD stated the second person could assist with the fall so, No one gets hurt. The DSD stated the facility provided an in-service (staff education) on Hoyer lifts around the end of 2/2025, and CNA 4 attended the in-service. The DSD stated it was possible that when two staff were operating the Hoyer lift then Resident 1's fall and injuries could have been prevented. During a telephone interview on 5/30/2025 at 12:54 pm with CNA 4, CNA 4 stated on 5/26/2025 (unable to remember exact time), CNA 4 was assigned to care for Resident 1. CNA 4 stated there were only five (5) CNAs working on Station 3 that day (5/26/2025). CNA 4 stated when CNA 4 transferred Resident 1 in the Hoyer lift, CNA 4 did not ask for a second staff to help because, Everyone was so busy and there weren't enough people on our station (Station 3). CNA 4 stated, I didn't really think to ask for help because of it (short-staffed). CNA 4 stated CNA 4 was getting Resident 1 ready for a shower and had hooked Resident 1 into the Hoyer lift sling and was using the Hoyer lift and, All of a sudden the (Hoyer) lift gave out. CNA 4 stated the Hoyer lift made a noise and CNA 4 saw the sling and Resident 1 tilting down toward the floor. CNA 4 stated, It's hard to describe the angle. CNA 4 stated Resident 1 and the Hoyer lift fell to the floor. CNA 4 stated, I was holding onto Resident 1 and got hurt myself. CNA 4 stated I'm not sure how it happened. CNA 4 stated there were supposed to be two staff operating the Hoyer lift for safety reasons. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated if two staff were operating the Hoyer lift when CNA 4 was transferring Resident 1, it was possible Resident 1's fall and injuries could have been prevented. The DON stated, When we don't follow our education and training, and there are not enough staff working, it can lead to consequences like injury and fall. During a review of the facility's most updated P&P titled, Safe Lifting and Movement of Residents, revised 7/2017, the P&P indicated, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 4 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete lift and move residents. The P&P indicated, Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The P&P indicated only staff with documented training on the safe use and care of the machines and equipment (Hoyer lift) used in this facility will be allowed to lift or move residents. The P&P indicated, Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Event ID: Facility ID: 055449 If continuation sheet Page 5 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to provide sufficient number of nursing staff according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent, and Facility Assessment Tool (FA Tool), by failing to: 1. Ensure certified nursing assistants (CNA) were not assigned more than 12 residents on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 on the 11 pm to 7 am (noc) shift on Station 3. 2. Ensure there were seven assigned CNAs on the 7 am to 3 pm (morning) shift in Station 3 on 5/26/2025. As a result of these failures, on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 CNAs working in Station 3 were assigned between 24 and 25 residents during the noc shift. On 5/26/2025, there were five CNAs working in Station 3 during the AM shift. Resident 1 had a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) while being transferred (moving a resident from one place to another) in a Hoyer lift (mechanical lift- a device used by staff to transfer residents from one location to another e.g., a bed to a chair) due to CNA 4 operating the lift without assistance. Resident 1 was sent to general acute care hospital (GACH) 1 for further evaluation. These failures have the potential to result in residents not receiving the appropriate care and services needed to treat their medical conditions. Cross Reference F689 Findings: 1. During an interview on 5/28/2025 at 2:56 pm, with CNA 3, CNA 3 generally worked the noc shift. CNA 3 stated it was, a common trend, where the facility is understaffed three days a week. CNA 3 stated CNA 3 was offered (by the facility) to work overtime (working outside of regular working hours) for the 3 pm to 11 pm (evening) shift because there were not enough CNAs scheduled. CNA 3 stated when the facility was short-staffed CNAs on noc shift, CNA 3 and one other CNA were generally assigned 24-25 residents on Station 3. CNA 3 stated when that happens, CNA 3 stated, I absolutely cannot provide safe and effective care to 24-25 residents. CNA 3 stated, I cannot ensure [residents] are repositioned every two hours, or make sure they are changed in a timely manner or ensure a safe environment for them. During a concurrent interview and record on 5/30/2025 at 12:07 pm, with the Director of Nursing (DON) and the Director of Staffing Development Assistant (DSDA), the Nursing Staffing Assignment and Sign-In Sheet (NSASS) for Station 3 noc shift dated 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 were reviewed. The DON stated on 5/6/2025, there were two CNAs working and each CNA had 24 residents. The DON stated on 5/7/2025, there were two CNAs working and each CNA had 24 residents. The DON stated on 5/14/2025 and 5/15/2025, there two CNAs working and each CNA had 24 and 25 residents both days. The DON stated on 5/18/2025, there were two CNAs working and each CNA had 24 residents. The DON stated CNAs were not supposed to be assigned 24 or 25 residents because, It's too much to take care of because it's a risk for patient care safety. 2. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 6 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some obesity (chronic disease characterized by excessive fat accumulation) and acute respiratory failure (a serious condition that makes it difficult to breathe on one's own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During an interview on 5/29/2025 at 11:46 am with LVN 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 7 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility was short-staffed on Station 3 (the station where Resident 1 resides) that day (5/26/2025). LVN 2 stated there were supposed to be seven (7) CNAs in Station 3 that day (5/26/2025) but there were only five (5) CNAs. During a telephone interview on 5/29/2025 at 3:48 pm with the Director of Staffing Development (DSD), the DSD stated in Station 3 there should be four CNAs scheduled on the noc shift and the CNAs should not have more than 12 residents assigned to them. DSD stated if the Facility Assessment indicated nine CNAs should be scheduled in the skilled nursing area during the AM shift, then nine CNAs should be scheduled to work in Station 3 so each CNA would have seven residents so the CNAs could provide adequate care to the residents, residents could be changed as needed, kept clean, dry and comfortable, get call lights answered on time, and receive snacks and meals when requested. The DSD stated it was not appropriate for CNAs to have 20-25 assigned residents during the noc shift because, It is a huge safety concern and is too much burden on staff and the residents. The DSD stated CNAs should not have that many residents in any capacity for any length of time. During a concurrent interview and record review on 5/30/2025 at 12:07 pm, with the Director of Nursing (DON) and Director of Staffing Development Assistant (DSDA), the facility's NSASS dated 5/26/2025, morning shift, was reviewed. The DSDA stated during the morning shift on Station 3, the facility needed six to seven CNAs depending on the census. The DON stated on 5/26/2025 the NSASS indicated there were five CNAs working in Station 3. The DON stated after CNA 4 left the facility (time unspecified) there four CNAs working in Station 3. The DON stated the NSASS was redone to indicate CNA 5 was added to the NSASS, indicating five CNAs worked in Station 3 during the morning shift. During a telephone interview on 5/30/2025 at 12:54 pm with CNA 4, CNA 4 stated on 5/26/2025 (unable to remember exact time), CNA 4 was assigned to care for Resident 1. CNA 4 stated there were only five (5) CNAs working on Station 3 that day (5/26/2025). CNA 4 stated when CNA 4 transferred Resident 1 in the Hoyer lift, CNA 4 did not ask for a second staff to help because, Everyone was so busy and there weren't enough people on our station (Station 3). CNA 4 stated, I didn't really think to ask for help because of it (short-staffed). CNA 4 stated CNA 4 was getting Resident 1 ready for a shower and had hooked Resident 1 into the Hoyer lift sling and was using the Hoyer lift and, All of a sudden the (Hoyer) lift gave out. CNA 4 stated the Hoyer lift made a noise and CNA 4 saw the sling and Resident 1 tilting down toward the floor. CNA 4 stated, It's hard to describe the angle. CNA 4 stated Resident 1 and the Hoyer lift fell to the floor. CNA 4 stated, I was holding onto Resident 1 and got hurt myself. CNA 4 stated I'm not sure how it happened. CNA 4 stated there were supposed to be two staff operating the Hoyer lift for safety reasons. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated it was important to have sufficient staffing to ensure resident safety. During a review of Facility Assessment Tool, the FA Tool indicated nine CNAs were recommended to be scheduled during the AM shift and five CNAs during the noc shift. During a review of the facility's P&P title, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated the facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide related care and services for all residents in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 8 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete accordance with resident care plans and the facility assessment. The P&P indicated staffing numbers and the skill requirements of direct care staff are determined by the needs of the resident based on each resident's care plan, the resident assessments, and the facility assessments. The P&P indicated factors considered in determining appropriate staffing ratios and skills included evaluation of diseases, conditions, physical or cognitive limitations of the resident population, and acuity. The P&P indicated minimum staffing requirements imposed by the state nursing assistant staffing ration to meet resident needs must be at a minimum of 2.4 and overall, 3.5, if applicable, were adhered to when determining staff ratios, but are not necessarily considered a determination of sufficient and competent staffing. Event ID: Facility ID: 055449 If continuation sheet Page 9 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff had the appropriate skills and competency necessary to provide nursing care and services to one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Staffing, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: Ensure Certified Nursing Assistant (CNA) 4 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from Resident 1's bed to the shower gurney (mobile bed used to assist in bathing residents) when CNA 4 used the Hoyer lift. As a result of this failure, on 5/26/2025 at 9:45 am, Resident 1 fell (move downward, typically rapidly and freely without control, from a higher to a lower level) to the floor from the Hoyer lift. Resident 1's back of head and neck hit the floor and Resident 1's right lower leg was pinned (trapped) between the shower gurney and Hoyer lift. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 5/26/2025 at 12:14 pm for further evaluation and was monitored for a closed head injury (any injury to the head that do not break through the skull [bone of the head that surround the brain]), right lower leg swelling, and blunt trauma (injury caused by a forceful impact, usually with a dull object or surface, that does not pierce the skin) to the neck. Cross reference F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid obesity (chronic disease characterized by excessive fat accumulation) and acute respiratory failure (a serious condition that makes it difficult to breathe on one's own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 1's Care Plan (CP) titled, Care Plan Report, revised 3/27/2023, the CP indicated Resident 1 had activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily)/self-care deficit due to requiring assistance with ADLs. The CP interventions included for staff to provide Resident 1 a safe environment and follow bed mobility (ability to move around in bed)/ADL standard of care. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 10 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. The COC form indicated the top of the Hoyer lift was caught by the shower gurney, and CNA 4's left arm was wedged between Resident 1 and the shower gurney in assist to the fall. The COC form indicated Resident 1's (right) leg was noted to be caught between the sides of the shower gurney. The COC form indicated Resident 1 had pain (pain level unrated) to Resident 1's right lower leg, bruising (skin discoloration from damaged, leaking blood vessels underneath the skin) to Resident 1's right lower leg and right finger (location unspecified), and lump (bump or a solid mass without a regular shape) on the back right side of Resident 1's head. The COC form indicated Nurse Practitioner (NP- a nurse with advanced clinical education and training) 1 was notified and ordered to transfer Resident 1 to GACH 1 for further evaluation. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During an interview on 5/29/2025 at 11:46 am with Licensed Vocation Nurse (LVN) 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated LVN 2 was two doors down from Resident 1's room when LVN 2 heard CNA 4 asking for help in Resident 1's room. LVN 2 stated when LVN 2 came into Resident 1's room, LVN 2 saw that the Hoyer lift was in between Resident 1's bed and Resident 1's roommate's bed, tilted over on its right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 11 of 12 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 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few side but was stopped by the shower gurney. LVN 2 stated LVN 2 found CNA 4 still assisting Resident 1 and trying to stop Resident 1 from falling by wedging CNA 4's left arm between Resident 1's right leg and the shower gurney. LVN 2 stated one of the bolts (a screw-like metal object without a point, used to fasten things together) on the Hoyer lift popped out. LVN 2 stated LVN 2 and other staff (unidentified) had to work to get the cuffs (the end part, usually thicker) off the sling to free Resident 1's (right) leg. LVN 2 stated after LVN 2 and other staff (unidentified) freed Resident 1's right leg, LVN 2 noticed Resident 1's right leg injury. LVN 2 stated Resident 1's right leg was instantly a goose egg (when blood collects between the skin and the muscle). LVN 2 stated less than 30 minutes after Resident 1 fell, Resident 1 complained of a bump on the back right side of Resident 1's head. LVN 2 stated the Treatment Nurse (TN) assessed Resident 1's head, while LVN 2 called 9-1-1 (phone number used to contact emergency services in the event of a medical emergency). During a concurrent record review and telephone interview on 5/29/2025 at 3:48 pm with the Director of Staff Development (DSD), the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025 was reviewed. The [NAME] indicated staff would Verbalize the understanding of facility policy requiring Two-Person Assist when using a (Hoyer) lift . Acknowledge that one-person lift will lead to suspension or possible termination. The [NAME] indicated CNA 4 signed the [NAME] to confirm CNA 4 attended the training dated 2/19/2025. The DSD stated CNA 4 needed to be operating the Hoyer lift with another staff member (two-person physical assistance) in case there was an issue with the Hoyer lift such as a malfunction. The DSD stated the second person could assist with the fall so, No one gets hurt. The DSD stated the facility provided an in-service (staff education) on Hoyer lifts around the end of 2/2025, and CNA 4 attended the in-service. The DSD stated it was possible that when two staff were operating the Hoyer lift then Resident 1's fall and injuries could have been prevented. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated if two staff were operating the Hoyer lift when CNA 4 was transferring Resident 1, it was possible Resident 1's fall and injuries could have been prevented. The DON stated, When we don't follow our education and training, and there are not enough staff working, it can lead to consequences like injury and fall. During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with the resident care plans and facility assessment. The P&P indicated staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) person centered care, basic nursing skills, and communication. The P&P indicated competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that programming for staff training results in nursing competency and that training includes critical thinking skills and managing care in a complex environment with multiple interruptions. During a review of the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025, the [NAME] indicated staff would verbalize understanding of facility policy requiring two-person assist when using a lift. The [NAME] indicated CNA 4 attended the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055449 If continuation sheet Page 12 of 12