Health inspection·December 20, 2024

F 0552 During an observation on 12/17/2024 at 10:57 am in Resident 21's room, Resident 21 was sitting up in bed. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/17/2024 at 2:02 pm with the Assistant Director of Nursing (ADON), the ADON stated Resident 21's dosage of Mirtazapine was increased from 30 mg to 45 mg and Resident 21 should have consented prior to medication use. The ADON further stated it was important to have informed consent for all psychotropic medications for the residents to be aware of the medications they were taking including the risks, benefits, and adverse side effects. Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent Antipsychotic Medications, dated 1/12/2022, the P&P indicated, physician's orders related to the use of psychotherapeutic drug and/or antipsychotic drug, shall not be initiated until the facility is able to verify that the resident or their authorized representative has given informed consent. The P&P further indicated, the licensed nurse shall complete the informed consent document in the resident's health record prior to administering the medication or treatment and an increase in dosage shall require informed consent to be obtained verified and documented in the resident's health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 2 of 17 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 12/20/2024 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 call lights were within reach for three of three sampled residents (Residents 13, 17 and 35). Residents Affected - Some These deficient practices had the potential for the residents not to receive necessary care or receive delayed services to meet the residents' needs that could result in a fall or injury. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and chronic obstructive pulmonary disease (COPD, a chronic lung diseases causing difficulty in breathing). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 had severely impaired cognition (ability to understand). Resident 17 required moderate assistance (helper did less than half the effort) with oral hygiene, toileting hygiene and lower body dressing and maximal assistance (helper did more than half the effort) with shower. During a review of Resident 17's Care Plan (CP) titled Fall Risk, dated 3/7/2024, the CP indicated Resident 17 was at risk for falls secondary to history of falls and impaired balance (a condition that makes it difficult to maintain orientation and feel steady). The CP interventions included to keep the resident's call light and bed control within easy reach. During a concurrent observation in Resident 17's room and interview on 12/17/2024 at 10:03 am with the Activity Director (AD), Resident 17's call light was behind the headboard. The AD stated Resident 17 could not reach the call light. The AD stated Resident 17's call light should be close and next to the resident for the resident to use to call and ask for help and assistance. b. During a review of Resident 13's AR, the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) without dyskinesia (a movement disorder that involves involuntary muscle movements) 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 13's CP titled Fall Risk dated 2/20/2023, the CP indicated Resident 13 was at risk for falls secondary to history of falls prior to admission and impaired balance and poor safety awareness. The CP interventions indicated for nursing staff to keep call lights and bed controls within easy reach, encouraging the resident to call for assistance and for staff to answer the call light in a timely manner. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had severely impaired cognition for daily decision making. The MDS indicated Resident 13 was dependent to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 3 of 17 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 12/20/2024 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 personal hygiene. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 13's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 12/17/2024, the FRA indicated Resident 13 was assessed as high risk for fall due to disorientation, being chair bound, required the use of assistive devices and presence of predisposing disease condition. Residents Affected - Some During an observation on 12/17/2024 at 10:12 am in Resident 13's room, Resident 13 was awake and lying in bed. Resident 13's call light was clipped at the upper right side of the bed. Resident 13 was not able to reach the call light. During a concurrent observation and interview on 12/17/2024 at 10:18 am with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 13's call light was on the upper right side of the bed and the resident was unable to reach the call light. The CNA 1 stated, Resident 13's call light needed to be within reach all the time for Resident 13 to use to ask for assistance or help. c. During a review of Resident 35's AR, the AR indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures (convulsions) over time) and right hand contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of Resident 35's CP titled Fall Risk, dated 8/15/2023, the CP indicated Resident 35 was at risk for falls secondary to impaired balance and poor safety awareness. The CP interventions indicated for nursing staff to keep call lights and bed controls within easy reach, encourage the resident to call for assistance and staff to answer call light in a timely manner. During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35 had severely impaired cognition for daily decision making. The MDS indicated Resident 35 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 35's FRA dated 12/17/2024, the FRA indicated Resident 35 was assessed as high risk for fall due to disorientation, being chair bound, requiring the use of assistive devices and presence of predisposing disease condition. During an observation on 12/17/2024 at 9:59 am in Resident 35's room, Resident 35 was asleep, lying in bed. Resident 35's call light was hanging on top of the headboard. During a concurrent observation and interview on 12/17/2024 at 10 am, with the facility's Assistant Director of Nursing (ADON), the ADON stated Resident 35 was unable to reach the call light because it was hanging on the top of the headboard. The ADON stated Resident 35's call light needed to be within reach for Resident 35 to use to call staff if Resident 35 needed assistance. During an interview on 12/17/2024 at 10:19 am with the facility's ADON, the ADON stated residents call light needed to be within reach for residents to use when needed and staff could assist residents in a timely manner. During an interview on 12/18/2024 at 3:16 pm with the facility's Director of Nursing (DON), the DON stated residents call light needed to be within reach, for staff to attend to the resident's needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 4 of 17 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 12/20/2024 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 immediately. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, dated 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. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 5 of 17 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 12/20/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment for one of one resident (Resident 51). Residents Affected - Few This failure resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 51 not to receive interventions to address the resident's specific care concerns. Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare (the treatment and care the patient received after surgery) following surgery on the digestive system (group of organs that work together to digest and absorb nutrients from food) and chronic kidney disease (progressive damage and loss of function of the kidneys). During a review of Resident 51's Physician's Order (PO) dated 10/1/2024, the PO indicated Resident 51 had an order to discharge home on [DATE] with home health nurse (a registered nurse who provides medical and personal care to patients in their homes), physical therapy/occupational therapy (PT/OT), walker (a mobility aid that helps provide stability and balance while walking), wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk) and bedside commode (a portable toilet) as requested by the family. During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 was discharged to an acute hospital. During a review of Resident 51's Licensed Personnel Progress Notes (LPPN) dated 10/8/2024, the LPPN indicated Resident 51 was discharged home and left the facility in stable condition. During a concurrent interview and record review on 12/18/2024 at 2:24 pm with Minimum Data Set Coordinator (MDS C), Resident 51's MDS, dated 10/8//2024 was reviewed. The MDS C stated Resident 51's discharge status was coded in error in the MDS and did not reflect the accurate information where the resident was discharged . The MDS C stated the MDS discharge status should be coded as discharge home under the care of organized home health service organization. During an interview on 12/18/2024 at 3:36 pm with the Director of Nursing (DON), the DON stated accurate assessment reflected the condition and care the resident needs. The DON stated accurate assessment and documentation were important for accurate reporting to the CMS. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, revised November 2019, the P&P indicated, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the OBRA and PPS required assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 6 of 17 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 12/20/2024 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 - Few 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** Based on observation, interview, and record review, the facility failed to utilize bilateral landing mats as ordered, for one of three sampled residents (Resident 13) who had a history of falls. This deficient practice had the potential to result in serious consequences that may accompany a fall for Resident 13. Findings: During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) without dyskinesia (a movement disorder that involves involuntary muscle movements) 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 13's Order Summary Report (OSR) dated 2/27/2022, the OSR indicated for staff to place bilateral floormat for fall precaution every shift, for Resident 13. During a review of Resident 13's Care Plan (CP) titled Fall Risk, dated 2/20/2023, the CP indicated Resident 13 was at risk for falls secondary to history of falls prior to admission, impaired balance, and poor safety awareness. The CP interventions indicated for nursing staff to place floor mat on both sides of Resident 13's bed. During a review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/14/2024, the MDS indicated Resident 13 had severely impaired cognition for daily decision making. The MDS indicated Resident 13 was dependent to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 13's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling), dated 12/17/2024, the FRA indicated Resident 13 was assessed as at high risk for fall due to disorientation, being chair bound, requiring the use of assistive devices and presence of predisposing disease condition. During an observation on 12/17/2024 at 9:59 am in Resident 13's bedroom, Resident 13 was awake and lying in bed. Resident 13's right landing floor mat was placed approximately 1 foot away from Resident 13's bed. During an interview on 12/17/2024 at 10:01 am with the facility's Assistant Director of Nursing (ADON), the ADON stated floor mats needed to be placed closer to Resident 13's bed to catch Resident 13 in case of a fall and to prevent fatal injuries that could happen associated with a fall. During an interview on 12/18/2024 at 3:29 pm with the facility's Director of Nursing (DON), the DON stated Resident 13's floor mats needed to be placed closer to Resident 13's bed. The DON stated, the purpose of the floor mat was to minimize injury to Resident 13 in case accident happened, such as a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 7 of 17 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 12/20/2024 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 During a review of the facility's Policy and Procedure (P&P) titled, Fall Risk Assessment, revised 3/2018, the P&P indicated, the staff and attending physician will collaborate to identify an address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are modifiable. Such intervention may include the use of a landing mattress to minimize the effects of any potential injury which may occur. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 8 of 17 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 12/20/2024 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** Based on observation, interview, and record review, the facility staff failed to ensure one of one sampled resident (Resident 40) received two liters of oxygen as needed according to physician's order and monitor the resident's oxygen usage in accordance with professional standards of practice. Residents Affected - Few This deficient practice had the potential to cause complications associated with oxygen therapy for Resident 40. Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening blood infection), respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 40's Order Summary Report (OSR) of Active Orders dated 7/15/2024, the OSR indicated Resident 40 had an order for two liters per minute (L/min) of oxygen via (through) nasal cannula (NC- tubing used to deliver oxygen that has two prongs that rest in the nostrils and connects to the oxygen concentrator) as needed to keep oxygen saturation above 92% for acute respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 40's History & Physical (H&P) dated 7/21/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool) dated 10/22/2024, the MDS indicated Resident 40 had intact cognition (ability to understand) and needed supervision or touching assistance (helper provides verbal cue and/or touching/steadying and/or contact guard assistance as the resident completes the activity with assistance provided throughout the activity or intermittently) for eating and was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene and showering/bathing. During an observation on 12/17/2024 at 11:06 am in Resident 40's room, Resident 40 was in bed receiving five L/min of oxygen with humidification through a NC. During another observation on 12/17/2024 at 12:39 pm in Resident 40's room, Resident 40 was in bed receiving five L/min of oxygen with humidification through a NC. During a review of Resident 40's Pain Assessment Flow Sheet for December 2024 and Medication Administration Record (MAR) for December 2024, the documents indicated Resident 40 was receiving opioid analgesics (a class of drugs used to treat pain that can cause respiratory depression) of Tramadol (narcotic pain medication used to treat moderate to severe pain) 50 mg and Norco (hydrocodone-acetaminophen- narcotic analgesic for the treatment of moderate to moderately severe pain) oral tablet 10-325 mg for pain, almost daily. During a concurrent interview and record review on 12/19/2024 at 10:08 am with Licensed Vocational (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 9 of 17 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 12/20/2024 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 Residents Affected - Few Nurse 2 (LVN 2), Resident 40's Medication Administration Record (MAR) for December 2024 was reviewed. The MAR did not indicate documentation (charting) on Resident 40 for the use of two L/min of oxygen via NC as needed to keep oxygen saturation above 92% for the month of December. LVN 2 stated Resident 40 was receiving two L/min of oxygen and last received Norco 10-325mg on 12/19/2024 at 6:30 am. LVN 2 further stated, Resident 40's oxygen use should be documented to ensure the resident was receiving sufficient oxygen. During a concurrent observation and interview on 12/19/2024 at 10:16 am with LVN 2 in Resident 40's room, Resident 40 had ongoing oxygen at five L/min via NC. LVN 2 stated, the licensed nurse was responsible for monitoring the resident's oxygen to ensure it was set at the correct level and that the physician's order was followed. LVN 2 further stated, Resident 40 should only receive two L/min of oxygen as ordered. During an interview on 12/19/2024 at 12:20 pm with the Assistant Director of Nursing (ADON), the ADON stated Resident 40 was on oxygen continuously and that monitoring the resident's oxygen levels was necessary to check for respiratory distress and determine if interventions were effective or if the resident needed more supplemental oxygen. The ADON further stated, licensed staff should have been charting and monitoring Resident 40's oxygen usage to determine how often oxygen was needed and to assist the facility staff in obtaining appropriate orders for Resident 40 based on the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated the purpose of the P&P was to provide guidelines for safe oxygen administration. The P&P indicated, to review the physician's orders, adjust the oxygen delivery device so proper flow of oxygen is being administered, and to record oxygen administration in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 10 of 17 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 12/20/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 48's AR, the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included fracture (a complete or partial break in a bone) of the first and second lumbar vertebrae (bones that make up the lower part of the spine) and acute kidney failure (a condition in which the kidneys can't filter waste from the blood). During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had intact cognition. The MDS indicated Resident 48 required maximum assistance (helper did more of the effort) with oral hygiene, upper body dressing and personal hygiene and was dependent (helper did all of the effort, resident did none of the effort to complete the activity) with toileting hygiene, shower, and lower body dressing. During a concurrent observation and interview on 12/17/2024 at 10:06 am inside Resident 48's room, Resident 48 was in bed on her back with 1/4 side rails up on both sides of the bed. Resident 48 was alert and oriented. Resident 48 stated she did not know why she had the side rails up. Resident 48 was not using the side rails. During a concurrent interview and record review on 12/18/2024 at 9:00 am with the Assistant Director of Nursing (ADON), Resident 48's medical records (chart) were reviewed. The ADON stated, there were no documentation that alternative interventions were attempted to use before side rails were installed on Resident 48's bed. During a review of the facility's Policy and Procedure (P&P) titled, Proper Use of Side Rails, revised 12/2016, the P&P indicated, the purpose of the guideline was to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. The P&P indicated documentation will indicate if less restrictive approaches are not successful, prior to the considering the use of side rails, risks and benefits of side rails will be considered for each resident, and consent for side rail use will be obtained from the resident after presenting potential benefits and risks. The P&P indicated, An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. The P&P indicated, documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. P&P indicated consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. b. During a review of Resident 33's AR, the AR indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) 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 33's OSR dated 11/5/2024, the OSR indicated an order for staff to apply upper bilateral one fourth (1/4) side rail for bed mobility every shift for Resident 33. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 had severely impaired cognition for daily decision making. The MDS indicated, Resident 33 was dependent to staff for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 11 of 17 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 12/20/2024 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 0700 toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene. Level of Harm - Minimal harm or potential for actual harm During an observation on 12/17/2024 at 10:27 am with Assistant Director of Nursing (ADON) inside Resident 33's room, Resident 33 was lying in bed on her back and bilateral upper side rails were up. Residents Affected - Some During a concurrent interview and record review on 12/17/2024 at 1:12 pm with the facility's Director of Nursing (DON), Resident 33's MR was reviewed. The DON stated there was no clinical documentation that appropriate alternatives were attempted before bedrail/siderails were used on Resident 33. The DON stated, when Resident 33 was re-admitted back to the facility, side rails were placed automatically. During a concurrent interview and record review of the facility's Policy and Procedure (P&P) titled, Proper Use of Side rails, on 12/20/2024 at 9:19 am with the facility's DON, the DON stated, use of appropriate alternatives should have been attempted before the use of bed rails as indicated in the policy. The DON stated bed rails could cause serious injury such as entrapment to the resident. Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Residents 21, 33 and 48) by failing to: a. (1). Ensure appropriate alternative interventions were attempted before the installation of side rails for Resident 21. (2). Assess Resident 21 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and obtained an informed consent to review the risks and benefits prior to installing bed rails. b. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 33 before the installation of side rails. c. Ensure appropriate alternative interventions were attempted and did not meet the needs of Resident 48 before the installation of side rails. These failures placed Residents 21, 33 and 48 at risk for entrapment, injury or death from the use of side rails. Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), anemia (a condition where the body does not have enough healthy red blood cells), and dysphagia (difficulty swallowing). During a review of Resident 21's History & Physical (H&P) dated 6/12/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated 9/18/2024, the MDS indicated Resident 21 had moderately impaired cognition (ability to understand) and needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 12 of 17 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 12/20/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supervision or touching assistance (helper provides verbal cue and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittently) with moving from a sitting to standing position, transferring to and from a bed to a chair, wheelchair or side of the bed, and the ability to move on or off a toilet. During a review of Resident 21's Order Summary Report (OSR) - Active orders as of 12/1/2024, the OSR indicated the following: 1. Resident 21 was capable of giving informed consent and/or able to participate in his treatment plan, ordered on 6/11/2024. 2. Bilateral half side rails to aid with bed mobility and transfers, every shift, ordered 6/11/2024. During an observation on 12/17/2024 at 10:57 am, in Resident 21's room, Resident 21 was sitting up on the side of the bed and both half side rails on the bed were up. During a concurrent interview and record review on 12/17/2024 at 2:09 pm with the Assistant Director of Nursing (ADON), Resident 21's medical record (MR) was reviewed. The MR did not have Resident 21's Entrapment Risk Evaluation for Bedrails and the Bedrails Assessment and Consent. The ADON stated, Resident 21 had a history of falls and the bedrail consent and assessments should have been completed to determine if bedrails were appropriate to use for Resident 21. The ADON further stated, the facility failed to use alternative measures prior to bedrail usage for Resident 21. During an interview on 12/20/2024 at 9:19 am with the facility's Director of Nursing (DON), the DON stated as specified in the facility's Bed Rails policy and procedure, the facility should use the least restrictive, alternative interventions and approaches before using bedrails as bed rails could be an entrapment risk for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 13 of 17 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 12/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure food items were dated when it was first opened in one of two facility refrigerators. This deficient practice had the potential risk for food borne illnesses (infections caused by ingesting contaminated food or beverages) to the residents. Findings: During an observation and initial tour of the kitchen on 12/17/2024 at 9:24 am, together with the Lead [NAME] (LC), one unlabeled bag of tortilla and 2 pound (lbs.- unit of measurement) open bag of corn tortilla did not have a label or date when it was first opened, inside one facility refrigerator. The LC stated the bags of tortillas were not labeled nor dated when it was first opened. The LC stated the staff who opened the food item needed to label it with the date opened to keep track of how long the food item was opened. During an interview on 12/18/2024 at 12:01 pm with the Dietary Supervisor (DS), the DS stated, all food items needed to have a label with date opened to determine the use by date and to identify the life span of the food item. During a review of the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Goods, dated 2020, the P&P indicated newly opened food items will need to be closed and labeled with a delivery and open date and use by the date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 14 of 17 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 12/20/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for a resident on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) with indwelling medical device placed on Enhanced Barrier Precautions (EBP, infection control measures used to prevent the spread of multidrug-resistant organisms [MDROs] in healthcare settings) for one of six sampled residents (Resident 44). Residents Affected - Few This failure had the potential to expose Resident 44 to infection. Findings: During a review of Resident 44's admission Records (AR), the AR indicated Resident 44 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 44 had moderately impaired cognition (ability to understand). The MDS indicated Resident 44 required moderate assistance (helper did less than half the effort) with eating and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 44's Care Plan (CP) titled Dialysis dated 12/3/2024, the CP indicated Resident 44 was on hemodialysis due to ESRD and had a quinton catheter (non-tunneled central line catheter used to provide temporary access to a vein for hemodialysis) on the right upper chest. The interventions included for staff to monitor dialysis access site for signs and symptoms of infection. During a concurrent observation and interview on 12/17/2024 at 10:03 am with the Assistant Director of Nursing (ADON), Resident 44 was in bed on her back. Resident 44 had a permacatheter (a flexible tube inserted into a vein to provide long-term access to the bloodstream) dialysis access site on the right upper chest. The ADON stated Resident 44 was not on EBP. During an interview on 12/17/2024 at 1:11 pm with the Director of Nursing (DON), the DON stated Resident 44 had a central line and should be placed on EBP to prevent the spread of infection. During a review of the facility's Policy and procedure (P&P) titled, Infection Control: Enhanced Barrier Precautions (EBP), dated 6/18/2024, the P&P indicated, Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 15 of 17 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 12/20/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 observation on 12/17/2024 at 10:41 am 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, front wheel walkers and shower chairs in the rooms and provide care to the residents without difficulty and with enough space. During an interview on 12/18/2024 at 10:22 am with the facility's 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 above 19 rooms. During a review of the facility's Room Waiver Request (RWR), dated 12/18/2024, the RWR indicated the rooms had enough space for each resident's care and dignity and privacy issues were all in compliance. The RWR 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055544 If continuation sheet Page 16 of 17 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 12/20/2024 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 110 2 154 160 Level of Harm - Potential for minimal harm 111 2 154 160 112 2 154 160 Residents Affected - Some 114 2 147 160 115 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 observation on 12/19/2024 at 9:45 am inside room [ROOM NUMBER], room [ROOM NUMBER] had 4 residents. CNAs 2 and 3 were cleaning and changing Resident 35 inside the room. During an interview on 12/19/2024 at 10:00 am with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated staff had enough space to move around the resident's room. CNA 2 stated the room could fit a wheelchair, front wheel walker and a rolling shower chair with no difficulty. During an interview on 12/19/2024 at 10:04 am with CNA 3, CNA 3 stated CNA 3 was able to move wheelchairs and walkers inside the resident's room 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 17 of 17