Health inspection·December 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 8 to replace hand socks as ordered, because it affects Resident 8's dignity. The ADON stated hand socks were intended for the hands and foot socks were intended for the feet. During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life - Dignity, with a revised date of February 2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Event ID: Facility ID: 055544 If continuation sheet Page 2 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for staff to assist a resident in need) was within reach for one of one sampled resident (Resident 42). Residents Affected - Few This deficient practice had the potential to result in Resident 42 not receiving care and assistance in a timely manner. Findings: During a review of Resident 42's admission Record, the admission record indicated Resident 42 was admitted on [DATE], with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass) and malignant neoplasm of the brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others. The MDS indicated Resident 42 was cognitively intact (able to think and reason). The MDS indicated Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, toilet transfer and personal hygiene, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for chair/bed-to-chair transfer. During a concurrent observation and interview on 12/19/2023 at 9:49 am, in Resident 42's room, Resident 42 was lying in bed. Resident 42's call light was on the floor at the back of Resident 42's head of bed. Resident 42 stated she was not able to find the call light and not able to reach it. During an interview on 12/19/2023 at 9:58 am, Licensed Vocational Nurse 2 (LVN 2) stated, Resident 42's call light was on the floor and was not within reach of Resident 42. LVN 2 stated Resident 42's call light should be within reach of the resident so Resident 42 could use to call for help when needed. LVN 2 stated, residents would get hurt trying to get out of bed by themselves if the call light was not within reach. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 3/2021, the P&P indicated, when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 3 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to provide information of advance care planning (a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for one of one sampled resident (Resident 42). This deficient practice had the potential for facility staff to provide treatment against the resident's will. Findings: During a review of Resident 42's admission Record, the admission record indicated Resident 42 was admitted on [DATE], with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass) and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others. Resident 42 was cognitively intact (able to think, reason and organize). Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, toilet transfer and personal hygiene, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for chair/bed-to-chair transfer. During a review of Resident 42's Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated) Acknowledgement form, dated 10/5/2023, the AD acknowledgement form was not completed. During an interview on 12/19/2023 at 3:13 pm, Social Service Director (SSD) stated, there was no AD offered to Resident 42 in Resident 42's medical record. SSD stated the AD should be screened upon admission to get to know the resident's choices and treatment preferences. SSD stated, the AD provides care guidance for the residents so the facility could provide care and treatment to meet their wishes. SSD stated it was resident's right to formulate AD and complete the AD acknowledgement form. During a review of the facility's Policy and Procedure titled, Advance Directives, revised 12/2016, the P&P indicated, prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 4 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to provide a comfortable and home like environment for one of one sampled resident (Resident 42). Residents Affected - Few This failure had the potential to result in Resident 42 not residing in a comfortable environment that could affect Resident 42's quality of life. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 10/2/2023, with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass), and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, had ability to express ideas and wants and had ability to understand others. Resident 42 was cognitively intact (able to think, reasoning and organize). Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, toilet transfer and personal hygiene, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for chair/bed-to-chair transfer. During a concurrent observation and interview on 12/19/2023 at 9:49 am in Resident 42's room, Resident 42 was lying in bed. There was a suction device (a medical device used to eliminate fluids or gases like mucus, vomit, blood, saliva, serum, or other secretions from the body cavities) and canister (a container that holds the patient's secretions) on Resident 42's bedside nightstand and another suction device and canister in the opened drawer of the nightstand. The top of the nightstand surface and drawer were fully occupied by suction devices and canisters with tubes. Resident 42 stated, it is too messy here, it takes away my spaces. Resident 42 stated, she did not know why there were two sets of suction devices in her room. During an interview on 12/19/2023 at 9:58 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated one set of the suction device was from the facility and the other set was from the hospice (end of life care) agency. LVN 2 stated, the staff should not leave two sets of suction devices at the bedside because it took away drawer spaces from Resident 42. LVN 2 stated, the environment for Resident 42 was messy and not homelike. LVN 2 stated, the facility should provide clean, comfortable, and homelike environment to the residents to promote residents' quality of life. During a review of the facility's policy and procedure (P&P) titled, Environment-Homelike, revised in 5/2017, the P&P indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 5 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an individualized a person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives and interventions to meet the residents' needs for one of one sampled resident (Resident 5) as indicated in the facility's Policy and Procedure, titled Care Plans, Comprehensive. This deficient practice had the potential for Resident 5 not to receive appropriate care, treatment and/or services. Finding: During a review of Resident 5's admission record, the admission record indicated, the facility readmitted Resident 5 on 11/26/2023 with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) with mood disturbance and Alzheimer's Disease (a progressive disease with specific brain abnormalities marked by memory loss and progressive inability to function normally at even the simplest tasks). During a review of Resident 5's Order Summary Report, dated 11/26/2023, the report indicated for Resident 5 to receive Lexapro (Escitalopram, a medication to treat depression [a feeling of severe sadness or hopelessness]) 20 milligrams (mg) one tablet by mouth, one time a day for depression, manifested by self-report of feelings of sadness. During a review of Resident 5's Elopement Risk Evaluation, dated 11/26/2023, the evaluation indicated Resident 5 was assessed as moderate risk for elopement. The form indicated Resident 5 required care planning for risk for elopement. During a review of Resident 5's History and Physical (H&P) assessment dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/1/2023, the MDS indicated, Resident 5 required maximum assistance (helper does more than half of the effort) with toileting hygiene, shower and lower body dressing. During a concurrent interview and record review on 12/19/2023 at 2:55 pm with the facility's Director of Nursing (DON), Resident 5's medical record was reviewed. The DON stated there was no clinical documentation that a care plan was developed for Resident 5 who was on Lexapro. The DON stated a care plan was needed to be initiated and implemented for Resident 5's use of Lexapro for the resident to receive proper care and effective interventions from the nursing staff. During a concurrent interview and record review on 12/19/2023 at 3:18 pm with the facility's DON, Resident 5's medical record was reviewed. The DON stated there was no clinical documentation that a care plan was developed for Resident 5 who was risk for elopement. The DON stated a care plan should have been initiated and implemented to address Resident 5's risk for elopement for the resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 6 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0656 receive required care and services. Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated, the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. P&P indicated each resident's comprehensive person centered care plan will be consistent with [NAME] resident's rights to participate in the development and implementation of his or her plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 7 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview and record review the facility failed to revise a plan of care for one of one sampled resident (Resident 15), who sustained a fall from his bed on 9/25/2023 as indicated in the facility's policy Care Plans, Comprehensive. This deficient practice had the potential to place Resident 15 at risk for recurrent falls. Findings: During a review of Resident 15's admission record indicated, the facility admitted Resident 15 on 11/14/2021 with diagnoses that included Parkinson's disease (an age-related brain condition that affects movement resulting in lack of coordination and tremors) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/16/2023, the MDS indicated, Resident 15's cognition for daily decision making was severely impaired. The MDS indicated Resident 15 required total dependence with eating, oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 15's Care Plan titled, Fall Risk, initiated on 2/20/2023, the care plan indicated Resident 15 had history of falls prior to admission. Resident 15's care plan did not indicate Resident 15 had a fall on 9/25/2023. The care plan interventions indicated for nursing staff to keep the resident's bed at lowest position and to place bilateral floor mat. During a review of Resident 15's Post Fall Assessment, dated 9/25/2023, the Post Fall Assessment indicated Resident 15 was found lying next to the bed on Resident 15's floor mat. The Post Fall Assessment indicated Resident 15's care plan was revised. During a review of the Interdisciplinary Team (IDT) Conference Record dated 9/26/2023, the record indicated Resident 15 was found lying on her left side on the floor on 9/25/2023. During a review of Resident 15's Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 9/27/2023, the assessment indicated Resident 15 was assessed as high risk for fall. During a concurrent interview and record review on 12/20/2023 at 4:10 pm, with the facility Director of Nursing (ADON), Resident 15's medical record was reviewed. The DON stated, Resident 15's care plan was not revised to address interventions for Resident 15 after a fall on 9/25/2023. The DON stated, Resident 15's care plan needed to be revised to determine if fall interventions were effective or not. During a record review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive, revised December 2016, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 8 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an effective communication method for one of one non-English speaking sampled resident (Resident 18). Residents Affected - Few This failure had the potential for Resident 18 to not receive the necessary care and services due to the lack of effective communication aids. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 9/29/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problems) and type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high). During a review of Resident 18's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/20/2023, the MDS indicated Resident 18 had clear speech, usually understood others, and usually made self-understood. The MDS indicated Resident 18 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for eating, personal hygiene, and transfer. During a concurrent observation and interview on 12/19/2023 at 10:12 am, Resident 18 was lying in bed awake. There was a communication board (paper pamphlet that displays photos, symbols, or illustrations to help people with limited language skills express themselves) next to Resident 18's bedside stand. The communication board indicated the translation language was Arabic (the language of the Arabs, spoken in a variety of dialects). During an interview on 12/19/2023 at 10:26 am with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 18 did not speak English and Resident 18 spoke Arabic. CNA 1 stated, it was hard to communicate with Resident 18 due to language barrier and the communication board was not enough to understand the Resident 18's needs. CNA 1 stated, Resident 18's family member translated for Resident 18 when the family member visited the resident in the facility. CNA 1 stated, there was no other method for the staff to communicate with non-English speaking residents except the use of communication board. During an interview on 12/19/2023 at 2:16 pm with Social Service Director (SSD), SSD stated Resident 18 spoke Arabic and the facility did not have a staff that spoke Arabic. SSD stated, the facility used a communication board as a translation tool between the staff and non-English speaking residents. SSD stated, the facility needed to have more communication methods for non-English speaking residents when the communication board was not enough. SSD stated, it was important for the staff to be able to communicate with the residents so the staff can know their needs and the facility could assess the residents and provide the necessary care without delay. During a review of the facility's policy and procedure (P&P) titled, Environment-Homelike, revised in 5/2017, the P&P indicated, Providing and assisting residents with communication aids through the use of interpreters, staff members who can converse with the residents in their native language and/or communication boards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 9 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to assign a designated staff to coordinate with hospice care (end of life care) for one of one sampled resident (Resident 42). Residents Affected - Few This failure had the potential for Resident 42 to not receive individualized compassionate care that could affect Resident 42's quality of life. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 10/2/2023, with diagnoses that included difficulty walking, muscle wasting and atrophy (loss of muscle mass), and malignant neoplasm of brain (brain cancer). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 42 had clear speech, ability to express ideas and wants, and ability to understand others. Resident 42 was cognitively intact (able to think, reasoning and organize). Resident 42 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, toilet transfer and personal hygiene, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for chair/bed-to-chair transfer. During a review of Hospice 1's Care Visit Schedule for 10/2023, the Care Visit Schedule indicated, a Certified Home Health Aid (CHHA) was scheduled to visit Resident 42 on 10/4/2023, 10/7/2023, 10/11/2023, 10/14/2023, 10/18/2023, 10/21/2023, 10/25/2023, 10/28/2023, and 10/31/2023. There was no care visit schedule provided for 11/2023 and 12/2023. During a review of Hospice 1's Patient Care Sign In Sheet, undated, for Resident 42, the Patient Care Sign In Sheet indicated, CHHA 1 signed in and signed out on 10/5/2023, 10/6/2023, and 10/10/2023. During a review of Resident 42's Order Summary Report for 12/2023, the Order Summary Report indicated Resident 42 was admitted to the facility under care of Hospice 1 on 10/2/2023. During a concurrent interview and record review on 12/19/2023 at 2:41 pm with the Director of Nursing (DON), Resident 42's medical record was reviewed. DON stated, the facility had a communication binder at the nursing station for Resident 42 with Hospice 1. DON stated, Resident 42 had a monthly care visit schedule from Hospice 1 for CHHA and licensed nurse care, and the monthly schedule should be placed in the binder. DON stated, there was no care visit schedule for 11/2023 and 12/2023 in the binder. DON stated, CHHA 1 needed to sign in and sign out each time CHHA 1 provided hospice services and communicate with the facility staff to keep the facility staff informed. DON stated, there was no designated facility staff to coordinate services with hospice care. DON stated, it was important to have a designated staff to follow up and make sure hospice care was provided and resident needs were met. DON stated, there must be good communication between the hospice agency and the facility to provide hospice residents with consistent quality care to improve residents' quality of life. During a review of the facility's policy and procedure (P&P) titled Hospice Program, revised in 7/2017, the P&P indicated, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 10 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0684 Level of Harm - Minimal harm or potential for actual harm care provided is appropriately based on the individual resident's needs. A member of the IDT (interdisciplinary team) will coordinate care provided to the resident by our facility staff and the hospice staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 11 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility (the ability to move), osteoarthritis (degeneration of joint cartilage and bone), epilepsy (brain disorder in which a person has repeated seizures [convulsions]over time and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 17's Resident Care Plan (RCP) titled Falls dated 12/5/2022, the RCP indicated Resident 17 was at risk for falls/injury related to poor body balance/control, poor safety awareness/judgement, history of falls, seizure disorder (sudden, uncontrollable burst of electrical activity in the brain), arthritis (inflammation on one or more joints causing pain and stiffness) and osteoporosis (bones become brittle and fragile from loss of tissue). The RCP indicated the interventions included to provide Resident17 with a safe and clutter-free environment. During a review of Resident 17's MDS dated [DATE], the MDS indicated, Resident 17's cognition (ability to understand) for daily decision making was severely impaired. The MDS indicated Resident 17 required supervision with eating, oral, toileting hygiene and upper body dressing and moderate assistance with shower, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 12/19/2023 at 10:23 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 17's room, Resident 17 had a landing pad (bedside fall mats that are placed along the side of the bed and designed to help prevent injury from potential falls) all the way to the wall and away from Resident 17's bed. On top of the landing pad were a bedside table, a walker (a mobility aid used to help people walk) and a trash bin. LVN 1 stated Resident 17's landing pad needed to be clutter-free and placed close and next to Resident 17's bed to prevent injury in case of a fall or seizure. During a review of Resident 17's Physician's Oder dated 12/19/23 at 5:00 pm, the order indicated for staff to provide landing pad to Resident 17. During an interview on 12/22/2023 at 9:56 am with the Assistant Director of Nursing (ADON), the ADON stated landing pad should be placed next to the bed for the resident to land on the pad and not on the floor in the event of a fall or seizure. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment. With a revised date of March 2018, the P&P indicated, Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis or osteopenia). The staff and the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Such interventions may include the use of landing mattress to minimize the effects of any potential injury which may occur. Based on observation, interview, and record review the facility failed to implement fall intervention to utilize bilateral landing mats for two of two sampled residents (Resident 15 and Resident 17) who had history of falls as indicated in residents care plan titled Fall Risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 12 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 - Minimal harm or potential for actual harm Residents Affected - Some These deficient practices had the potential to result in serious consequences like fractures (break in the bone) and bleeding that may accompany with falls. Findings: a. During a review of Resident 15's admission record indicated, the facility admitted Resident 15 on 11/14/2021 with diagnoses that included Parkinson's disease (an age-related brain condition that affects movement resulting in lack of coordination and tremors) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/16/2023, the MDS indicated, Resident 15's cognition for daily decision making was severely impaired. The MDS indicated Resident 15 required total dependence with eating, oral and toileting hygiene. During a review of Resident 15's Care Plan titled, Fall Risk, initiated on 2/20/2023, the care plan indicated Resident 15 had history of falls prior to admission. The care plan did not indicate Resident 15 had an incident of fall for the last two to six months. The care plan interventions indicated for nursing staff to keep Resident 15's bed at the lowest position and place bilateral floor mat. During a review of Resident 15's Order Summary Report, dated 2/26/2022, the order indicated for staff to place bilateral floor mats for Resident 15 for fall precaution. During a review of Resident 15's Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 9/27/2023, the assessment indicated Resident 15 was assessed as high risk for fall. During a concurrent observation and interview on 12/19/2023 at 10:06 am, with Infection Prevention Nurse (IPN), Resident 15 was asleep in bed. The floor mat was placed next to the wall, approximately 1 foot and 1/2 away from the Resident 15's bed. The IPN stated, Resident 15's floor mat needed be closer to the resident's bed for it to catch the resident in case of a fall. The IPN stated Resident 15 had history of fall and the purpose of the floor mat was to prevent severe injury if Resident 15 had another fall. During a concurrent interview and record review on 12/19/2023 at 2:06 pm with the facility's Director of Nursing (DON), Resident 15's Fall Risk care plan was reviewed. The DON stated nursing staff needed to place bilateral floor mats next to Resident 15's bed. During a concurrent interview and record review on 12/19/2023 at 3:37 pm with the DON of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated examples of approaches include rearranging room furniture, etc. that included to place bilateral floor mats. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 13 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to follow the physician's order to set up Gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feeding of Fibersource HN (nutritionally complete tube feeding formula) via pump (a machine used to infuse nutrition formula through G-Tube to the stomach) for one of four sampled residents with tube feeding (Resident 28). This failure had the potential to result in weight loss and malnutrition for Resident 28 and could affect Resident 28's health condition. Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility readmitted Resident 28 on 12/15/2022, with diagnoses that included gastrointestinal hemorrhage (bleeding in digestive tract) and dysphagia (difficulty swallowing). During a review of Resident 28's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/31/2023, the MDS indicated Resident 28 had clear speech, usually understood others, and sometimes made self-understood. Resident 28 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for personal hygiene and bed-to-chair transfer. During an observation and concurrent interview on 12/19/2023 at 10:49 am, Resident 28 was sitting in the activity room watching TV. Resident 28 was on G-tube feeding. Resident 28's G-tube feeding pump was running at 80 milliliters (ml, unit of measurement) per hour (ml/hr) of water with a total of 320 ml water infused. Resident 28's G-tube feeding pump monitor screen indicated the pump was running the Fibersource HN formula at 0 ml/hr. Licensed Vocational Nurse 2 (LVN 2) stated, Resident 28's feeding pump was set up wrong and Resident 28 received 320 ml of water instead of 320 ml of formula in the last 4 hours of infusion. LVN 2 stated, the tube feeding formula was Resident 28's primary nutrition intake, and not receiving the nutrition as ordered might cause weight loss and malnutrition for Resident 28. LVN 2 stated, she needed to double check Resident 28's physician order to make sure the feeding pump was set up correctly to avoid possible decline of Resident 28's health condition. During a review of Resident 28's Order Summary Report for 12/2023, the Order Summary Report indicated Resident 28 was ordered Fibersource HN via pump at 80 ml/hr for 20 hours and water flushing of 30 ml/hr for 20 hours. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding Protocol, revised on 6/22/2021, the P&P indicated, Verify physician enteral order; confirm the following information prior to initiating enteral therapy: right resident to receive therapy, right time for therapy, right formula as prescribed in the enteral order, right route in order for the resident to received therapy. Each nursing shift is designated to check and insure correct enteral infusion rates and dose limits at the start of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 14 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 149's admission Record (AR), the AR indicated Resident 149 was admitted to the facility on [DATE], with diagnoses that included perforation of intestine (loss of continuity of the bowel wall) and cirrhosis of liver (liver is scarred and permanently damaged). Residents Affected - Some During a review of Resident 149's Resident Care Plan (RCP) titled Oxygen Therapy dated 12/15/2023, the RCP indicated, Resident 149 was on oxygen (colorless and odorless gas) therapy due to episodes of shortness of breath related to abdominal wound incision (a surgical cut made anywhere on the abdomen). The RCP indicated the interventions included to administer oxygen at 2 liter/minute (l/min, flow rate) via nasal cannula (a device that gives additional oxygen through the nose) as ordered. During a record review of Resident 149's Order Summary Report (OSR), dated 12/15/2023, the OSR did not indicate Resident 149 had an order for oxygen at 2 l/min via nasal cannula. During a concurrent observation and interview on 12/19/2023 at 10:18 am with the Assistant Director of Nursing (ADON) inside the Resident 149's room, the ADON stated Resident 149 had a continuous oxygen of 2 liters via nasal cannula. During a concurrent interview and record review on 12/20/2023 at 2:05 pm with the ADON, Resident 149's OSR, dated 12/15/2023 was reviewed. The OSR did not indicate an order for continuous use of oxygen for Resident 149. The ADON stated continuous or as needed use of oxygen required a doctor's order to determine the parameters (a numerical or measurable factor forming one of a set that defines a system or sets the condition of its operation) to ensure Resident 149 was not getting too little or too much oxygen. During an interview on 12/20/2023 at 2:15 pm with the Director of Nursing (DON), the DON stated continuous or as needed use of oxygen needed a doctor's order to support the plan of care for Resident 149. c. During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) and heart failure (a chronic condition in which the heart doesn't pump blood as it should). During a review of Resident 8's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 10/20/2023, the MDS indicated Resident 8 had severely impaired cognition and was totally dependent on staff with oral hygiene, toileting, shower, and personal hygiene. During a concurrent observation and interview on 12/19/2023 at 11:02 am with the ADON inside Resident 8's room, the ADON stated Resident 8 had a continuous oxygen of 3 liters per minute via nasal cannula. During a concurrent interview and record review on 12/20/2023 at 2:47pm with the ADON, Resident 8's Order Summary Report (OSR), dated 11/2023 and 12/2023 were reviewed. The OSR did not indicate an order for continuous use of oxygen for Resident 8. The ADON stated continuous or as needed use of oxygen required a doctor's order to determine the parameters to ensure Resident 8 was not getting too little or too much oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 15 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0695 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated P&P titled, Oxygen Therapy, the P&P indicated, It is the facility's policy to provide oxygen to residents, in a safe and therapeutic manner. Oxygen therapy shall be administered as ordered by the physician or as an emergency measure, such as signs and symptoms of respiratory distress. In which case administration of oxygen shall be done as a nursing measure. Once oxygen is applied, notify physician for further orders. Residents Affected - Some Based on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) for three of three sampled residents (Residents 199, 149 and 8) according to standards of practice and with the facility's Policy and Procedure (P&P) titled, Oxygen Therapy. a. Resident 199 did not receive two liters of oxygen as ordered by the physician. b. Resident 149 received continuous oxygen therapy without a physician's order. c. Resident 8 received continuous oxygen therapy without a physician's order. These deficient practices placed Residents 199, 149 and 8 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead to serious complications. Findings: a. During a review of Resident 199's admission Record, the admission record indicated the facility admitted Resident 199 on 12/12/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPDa type of obstructive lung disease characterized by long term poor airflow). During a review of Resident 199's Care Plan titled, Oxygen Therapy, dated 12/12/2023, the care plan indicated Resident 199 was on oxygen therapy. The care plan interventions included for nursing staff to administer oxygen at two liters per minute (L/min) through nasal cannula, as ordered and to change oxygen tubing and humidifiers every Sunday and as needed. During a review of Resident 199's History and Physical (H&P), dated 12/15/2023, the H&P indicated Resident 199 did not have the capacity to understand and make medical decisions. During an observation on 12/19/2023, at 9:46 am, with Licensed Vocational Nurse 2 (LVN 2), Resident 199 was asleep, lying in bed with oxygen concentrator on. Resident 199's nasal cannula tubing was hanging on the oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) and the nasal cannula tubing prongs were not placed in Resident 199's nares. During a concurrent observation and interview on 12/19/2023, at 9:48 am with LVN 2, LVN 2 stated oxygen concentrator should be turned off if not in used and the nasal prongs should be placed in the resident's nares when in use. During a concurrent record review and interview on 12/20/2023 at 2:36 pm with the facility's Director of Nursing (DON), Resident 199's Order Summary Report was reviewed. The Order Summary Report dated 12/12/2023 indicated to administer oxygen at two liters per minute via nasal cannula, may titrate between two to five L/min every shift for shortness of breath. The DON stated Resident 199 needed to receive continuous oxygen of two liters per minute via nasal cannula to ensure the desired oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 16 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0695 needed by the resident was administered as ordered by the physician and to prevent shortness of breath. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated P&P titled, Oxygen Therapy, the P&P indicated oxygen therapy shall be administered as ordered by the physician. The P&P indicated licensed nurse shall also check and ensure that correct oxygen flow rate is administered in accordance with physician order. The nasal cannula or face mask shall be checked for appropriate placement. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 17 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a performance evaluation for at least once every 12 months for one of two sampled Certified Nursing Assistants 3 (CNA 3). Residents Affected - Few This failure had the potential for the facility to not be aware of CNA 3's competency skills and techniques and miss the opportunity to provide the necessary in-service education specific to CNA 3's performance which could negatively affect the provision of care to residents. Findings: During a review of CNA 3's personnel file and Employee Evaluation Report, the report indicated CNA 3 had a general performance evaluation on 3/7/2022. There was no evaluation report for 2023 in CNA 3's personnel file. During an interview on 12/21/2023 at 10:21 am with the Director of Staff Development (DSD), DSD stated CNA 3's last performance evaluation was completed on 3/7/2022 and there was no performance evaluation completed for CNA 3 in 2023. DSD stated, CNA 3's annual performance evaluation should have been completed in 3/2023. DSD stated, performance evaluation should be done at least every 12 months for all staff to make sure staff skills were up to date and the facility was aware of staff weaknesses and strengths to provide quality and competent care to residents. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, revised in 6/2010, the P&P indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at lease annually thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 18 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to act upon the pharmacist's monthly medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation to obtain an informed consent for the use of Venlafaxine (medication used to treat depression, anxiety disorder and panic disorder) for one of five sampled residents (Resident 38) on psychotropic medication (medication that affects brain activities associated with mental process and behavior). This failure had the potential to result in Resident 38 receiving an unnecessary medication and could prevent Resident 38 from maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 9/20/2023, with diagnoses that included Type 2 diabetes mellitus (a disease in which there is a high level of sugar in the blood) and hemiplegia (paralysis on one side of the body). During a review of Resident 38's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 9/25/2023, the MDS indicated Resident 38 had clear speech, usually understood others, and usually made himself understood. The MDS indicated Resident 38 was totally dependent (full staff performance every time during entire 7-day period) with one-person physical assist for bed mobility, toilet use, and personal hygiene. During a review of Resident 38's Consultant Pharmacist's Medication Regimen Review (MRR), dated 10/5/2023, the MRR indicated, Resident 38 was on Venlafaxine and for the facility to make sure informed consent was obtained by the prescriber. During a review of Resident 38's Order Summary Report for 12/2023, the Order Summary Report indicated Venlafaxine 37.5mg (milligram) one tablet by mouth two times a day for neuropathic pain (pain caused by dysfunction in the nervous system) ordered on 9/20/2023. During an interview on 12/21/2023 at 8:47 am with the Assistant Director of Nursing (ADON), ADON stated she was in charge of reviewing the MRR report from the facility's pharmacist. ADON stated, she would review and act upon the pharmacist's recommendations. ADON stated, she was aware of the pharmacist's recommendation regarding obtaining an inform consent from the prescriber for Resident 38's use of Venlafaxine. ADON stated, she did not notify Resident 38's physician regarding the pharmacist's recommendation to obtain informed consent for the use of Venlafaxine. ADON stated, it was important to communicate with the resident's physician regarding the pharmacist's MRR to avoid possible medication error and unnecessary use of medications. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, undated, the P&P indicated, licensed charge nurse, if needed, shall follow up with primary care physician for actions recommended by the pharmacy consultant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 19 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the nasal cannula (NC, small flexible tube with two prongs that sit inside the nostrils to deliver supplemental oxygen) was labeled and dated, the tubing was not touching the floor, and the NC prongs were not touching the oxygen humidifier (device used to provide moistened oxygen) when not in use for one of three sampled residents (Resident 20) on oxygen therapy in accordance with the facility's policy and procedure titled, Oxygen Therapy. Residents Affected - Few This deficient practice had the potential to result in an increased risk of spread of infection to the residents, staff, and other visitors in the facility. Findings: During a review of Resident 199's admission Record, the admission Record indicated the facility admitted Resident 199 on 12/12/2023, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that block airflow and make it difficult to breathe). During a review of Resident 199's History and Physical (H&P), dated 12/15/2023, the H&P indicated, Resident 199 did not have the capacity to understand and make medical decisions. During a review of Resident 199's Order Summary Report, dated 12/12/2023, the Order Summary Report indicated, to administer oxygen at two (2) liters per minute (L/min) via nasal cannula and may titrate between 2 to 5 L/min every shift for shortness of breath. During a review of Resident 199's Care Plan titled, Oxygen Therapy, dated 12/12/2023, the care plan indicated, Resident 199 was on oxygen therapy. The care plan interventions included for the nursing staff to administer oxygen at 2 L/min via nasal cannula as ordered and to change the oxygen tubing and humidifiers every Sunday and as needed. During an observation on 12/19/2023 at 9:46 am with Licensed Vocational Nurse 2 (LVN 2), Resident 199 was asleep, lying in bed with the oxygen concentrator on. Resident 199's undated nasal cannula was not on the resident's nostrils. The nasal cannula tubing was hanging on the oxygen concentrator and touching the floor and the nasal cannula prongs were touching the oxygen humidifier. During a concurrent observation and interview on 12/19/2023 at 9:48 am with LVN 2, Resident 199's nasal cannula was observed. LVN 2 stated, Resident 199's nasal cannula tubing should not be touching the floor. LVN 2 stated, the tubing should be labeled with the date and the tubing should be stored in a bag when not in use to keep the tubing clean and for infection control. LVN 2 stated, the nasal cannula prongs should not be touching the oxygen humidifier and the tubing should not be touching the floor to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). LVN 2 stated, she would replace the whole tubing. During an interview on 12/19/2023 at 9:50 am with the Infection Prevention Nurse (IPN), the IPN stated the nasal cannula tubing should be labeled and not touching the floor because the floor was dirty and to prevent cross contamination. The IPN stated, nasal cannula should be stored in the storage bag if not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 20 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/2023 at 2:34 pm with the Director of Nurses (DON), the DON stated nasal cannula prongs should not be touching anything and should be stored in a bag if not in use to keep it clean. The DON stated, oxygen tubing should be off the floor because the floor was dirty and to prevent infection. The DON stated, nasal cannula tubing should not be touching the floor because it could cause cross contamination. Residents Affected - Few During a review of the undated facility's policy and procedure (P&P) titled, Oxygen Therapy, the P&P indicated, all apparatus shall be changed, labeled, and dated once a week on Sundays and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 21 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to meet the 80 square feet (sq. ft., a unit area of measurement) per resident in multiple resident bedrooms requirement for 18 of 24 resident rooms (Rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119 and 122) in the facility. This failure had the potential to affect residents' privacy and result in the residents not having adequate space for nursing care and emergency services. Findings: During an interview on 12/19/2023 at 9:39 am with the administrator (ADM), the ADM stated the facility had 18 out of 24 resident rooms that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms. The ADM submitted a room waiver for the 18 rooms. During an observation on 12/19/2023 at 2:14 pm in Station 1 and 2, rooms 101, 103, 104, 105, 106, 107, 110, 111, 112, 114, 115, 116, 117, 118, and 119 had 2 beds inside. Rooms 108, 109 and 122 had 4 beds inside. The residents and staff were able to move wheelchairs in the rooms and provide care without difficulty and with enough space. During a review of the facility's room waiver request, dated 12/19/2023, the room waiver request indicated, the rooms had enough space for each resident's care and dignity and privacy issues were all in compliance. The room waiver request indicated, each resident's necessity of equipment and fixtures had no negative effect on the care and movement of staff and other residents. The room waiver request indicated the following: Rm # # of beds Total sq. ft. Required sq. ft. 101 2 154 160 103 2 154 160 104 2 154 160 105 2 154 160 106 2 154 160 107 2 154 160 108 4 280 320 109 4 280 320 110 2 154 160 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 22 of 23 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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 0912 111 2 154 160 Level of Harm - Potential for minimal harm 112 2 154 160 114 2 147 160 Residents Affected - Some 115 2 147 160 116 2 154 160 117 2 154 160 118 2 154 160 119 2 154 160 122 4 280 320 During an interview on 12/21/2023 at 2:45 pm with Certified Nurse Assistant 4 (CNA 4), CNA 4 stated she was able to move wheelchairs and walkers inside the residents' rooms with ease and move with enough space when providing resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 23 of 23