Inspection visit

Health inspectionJune 11, 2021

THE ROWLANDCMS #05611726 citations on this visit

26 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 26 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a clean and homelike environment in three of 44 residents rooms (Rooms 313, 314 and 315). The privacy curtains in the rooms had brown and black stains. This deficient practice had the potential to result in an unsanitary environment, which may lead to wide spread infection in the facility and promote a non-homelike environment to the residents. Findings: During a concurrent facility tour with the Licensed Vocational Nurse (LVN 1) on 6/10/21 at 11:37 AM, the privacy curtain in room [ROOM NUMBER] was observed stained with a grey brown substance. During a concurrent observation and interview with the Registered Nurse Supervisor 2 (RN 2) on 6/10/21 at 12:10 PM, the privacy curtain in room [ROOM NUMBER] had grey and brown stains. RN 2 stated the curtains were washed, but the stains remained and should be cleaned again. During a concurrent observation and interview with the Director of Nursing (DON) on 6/11/21 at 10:11 AM, the privacy curtains in room [ROOM NUMBER] was observed with multiple splashes of dried brown substance. DON stated, the privacy curtain should be replaced. A review of the policy and procedure (P&P) titled, Cleaning and Disinfecting of Environmental Surfaces, dated 10/2009, indicated the walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 52 Event ID: 056117 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to do background checks (a process a person or company uses to verify that an individual is who they claim to be, and this provides an opportunity to check and confirm the validity of someone's criminal record, education, employment history, and other activities from their past), for two staff (Licensed Vocational Nurse [LVN] 3 and LVN 5) prior to employment in accordance to the facility's policy and procedure. Residents Affected - Few This deficient practice had the potential to place the residents at risk for harm and abuse. Findings: During an interview on 6/10/2021 at 3:28 pm, the Director of Staff Development (DSD) stated LVN 5's date of hire was 3/3/2021. During the concurrent interview and a review of LVN 5's employee file, DSD stated LVN 5's Office of the Inspector General (OIG, identifies individuals or entities that have been excluded from participation in Medicare), search result was dated 4/15/2021 (after the hire date), and LVN 5's California Megan's Law (provides information on registered sex offenders) Website (a set of pages or information in the internet) search result was dated 4/15/2021 (after the hire date). DSD stated the search date indicated the day the background check was done and stated the background check was done after LVN 5 was hired and not done prior. During an interview on 6/10/2021 at 3:45 pm, and review of LVN 3's file, DSD stated LVN 3's date of hire was 11/18/2019. DSD stated they conducted a background check through OIG and the California Megan's Law Website but there was no background check included in LVN 3's file as evidence. During an interview and a review of the facility's policies, on 6/11/2021 at 12:38 pm, DSD stated the facility's undated Abuse (treat a person with cruelty) Policy and Procedure (P&P) undated, indicated the facility would provide a safe environment for each resident by screening potential employees prior to hiring based on verification and documentation that employee had no known history of abuse or other negative actions. DSD stated this was the procedure they were supposed to follow, and it was important to make sure the staff did not have any criminal background such as abuse prior to hiring to ensure residents were safe as well as the other staff's safety. A review of the facility's Background Screening Investigation Policy revised 3/2019, indicated the facility designee conducted background checks and criminal conviction (have been found guilty of a crime by a court or that you have agreed to plead guilty to a crime) checks on all potential direct access employees (with direct access to residents). The policy indicated background check and criminal checks were initiated within two days of an offer of employment and completed prior to employment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 2 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 observation, interview and record review, the facility failed to develop and implement the individualized plan of care for one of 24 sampled residents (Residents 7) as indicated in the facility policy. Resident 7 did not have a care plan to prevent the recurrent dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). Resident 7's care plan to assess and monitor urine output, color, clarity, consistency and signs and symptoms of infection were not implemented. These deficient practices resulted to Resident 7 failing to receive necessary assessment, monitoring and interventions to prevent dehydration, bruises and bleeding. Findings: A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7 diagnoses included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins) and dementia (a progressive brain disorder that affects the thought process). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/24/21, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills for daily decision making. Resident 7 required extensive assistance with bed mobility and personal hygiene. Resident 7 was totally dependent with staff for transfer, dressing and toilet use. A review of the General Acute Care Hospital (GACH) record, indicated on 5/20/21, Resident 7 was admitted to the hospital with diagnoses that included renal failure, urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]), sepsis (infectin of the blood)and dehydration ( a state of losing more fluids than one take in or fluid depleted). During a facility tour on 6/8/21 at 10:31 AM, Resident 7 was observed asleep with a gastrostomy tube (GT, a tube inserted into the stomach to deliver nutritional formula, fluids and medications) feeding pump (machine) at bedside. During a concurrent record review and interview with the Licensed Vocational Nurse 2 (LVN 2) on 6/8/21 at 9:32 AM, she stated, Resident 7 was recently hospitalized for dehydration. LVN 2 stated, Resident 7 should have a care plan to address dehydration to ensure intake and output was done and the signs and symptoms of dehydration were monitored and documented. LVN 2 stated this was important to prevent recurrent dehydration. LVN 2 stated she could not find a documentation in Resident 7's clinical record that a plan of care was developed. A review of Resident 7's care plan, dated 4/7/21, indicated Resident 7 was at risk for infection due to presence of Foley Catheter (urinary indwelling catheter, tube inserted into the bladder to drain urine to a collection bag). The interventions included for Resident 7 to be free of infection were to assess, monitor urine output, color, clarity, consistency and signs and symptoms of infection. During a concurrent record review of Resident 7's care plan and interview with RN 2 on 6/10/21 at 12:41 PM, she stated there was no documented evidence the care plan to assess and monitor urine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 3 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 output, clarity, color, consistency and signs and symptoms of infection were implemented. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 10/2010, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It also indicated care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 4 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. 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 provide one of two sampled residents (Resident 39) an activity based on the activity assessment, care plan and facility policy. Residents Affected - Few This deficient practice had the potential not to meet the residents' interest and activity needs, which could affect the physical, mental, and psychosocial well-being of each resident. Findings: A review of the admission Record indicated Resident 39 was readmitted to the facility on [DATE]. Resident 39's diagnoses included epilepsy (seizure, a brain disorder caused by uncontrolled electrical activity which can result in convulsions, sensory disturbances or loss of consciousness) without status epilepticus (seizure that lasts longer than 5 minutes without a return to consciousness), cerebral palsy (a disorder that affects the ability to move and maintain balance and posture), stress incontinence (inability to control urge to urinate), intellectual disabilities and osteoarthritis (degenerative joint disease). A review of the quartely Minimum Data Set (MDS, standardized assessment and care screening tool), dated 4/9/21 indicated Resident 39's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making was modified independence. Resident 39 required extensive assistance with bed mobility, transfer, and dressing. Resident 39 was totally dependent on the staff with toilet use and personal hygiene. A review of the annual MDS, dated [DATE] indicated activity preferences very important to Resident 39 were keep up with the news, do your favorite activities, and participate in religious services or practices. During an observation on 6/9/21 at 10:08 a.m., in the hallway, Resident 39 was upset and was crying loudly as the Activity Director (AD) pushed her wheelchair back to her room. Resident 39 stated she did not want to go back to her room. A review of Resident 39's physician order, dated 6/1/2021, indicated may participate in activity, as tolerated, and if not in conflict with plan of care. During an interview on 6/9/21 at 10:09 a.m., Resident 39 stated she wanted to stay in the dining room, but the AD did not let her. Resident 39 stated she liked being in the dining area and did not want to go back to her room. Resident 39 stated she did not want to be in her room because it was boring. On 6/9/21 at 10:10 a.m., during an interview, AD stated she brought Resident 39 back to her room because there was no supervision available to watch the residents in the dining room. The AD stated it was Coffee Time and staff were busy going around pouring coffee for the residents in their rooms. The AD stated Resident 39 did not require supervision in the room. A review of the Resident Activities Assessment, dated 10/15/20 indicated activity preferences very important to Resident 39 were to do things with groups of people, do favorite activities, and go outside to get fresh air when the weather is good. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 5 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of Care Plan titled, Activities, dated 3/20/21, indicated Resident 39's interventions were to assess activity of choice, allow to have choices with activities, provide alternative choices and provide ongoing resident centered activities that promotes mental and psycho-social needs. A review of the facility policy and procedure (P&P) titled, Activities and Social Services, revised 12/2006, P&P indicated Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. The policy also indicated the facility will provide activities, social events, and schedules that are compatible with the resident's interest, physical and mental assessment, and overall plan of care. Event ID: Facility ID: 056117 If continuation sheet Page 6 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the necessary care and treatment for two of 24 sampled residents (Resident 7 and 15) as indicated on the care plan and facility policy. Residents Affected - Few a.1. There was no documented evidence Resident 7 was monitored for the presence of bruises (reddish purple discoloration) on both hands. a.2. There was no documented evidence Resident 7's moisture-associated skin damage (MASD, skin injury characterized by the inflammation and skin erosion due to prolonged exposure to moisture and irritants such as urine, stool, perspiration and wound exudates [discharge]) on the left and right buttock was assessed and documented daily for size and appearance. b. There was no documented evidence Resident 15's MASD on the sacrococcyx (tailbone) was assessed and monitored for any changes in status. This deficient practice had the potential to result in lack or delayed care, which could worsen Resident 7 and 15's bruises and MASD. Findings: a.1. A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7's diagnoses included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins) and dementia (a progressive brain disorder that affects the thought process). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/24/21, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills for daily decision making. Resident 7 required extensive assistance with bed mobility and personal hygiene. Resident 7 was totally dependent with staff for transfer, dressing and toilet use. During a facility tour on 6/8/21 at 10:31 AM, Resident 7 was observed in bed asleep and with bruises on both hands. During a record review and concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 6/8/21 at 9:32 AM, she stated Resident 7 was receiving Pentoxifylline ER (medication used to improve blood flow in patients with circulation problems to reduce aching, cramping, and tiredness in the hands and feet. It works by decreasing the thickness of the blood) with the side effect of bruising. LVN 2 stated, Resident 7 should be monitored for bruises because of the medication as indicated on the care plan. LVN 2 stated she could not find a documentation that Resident 7 was assessed and monitored for the appearance and size of bruising. LVN 2 stated this was important to determine if the bruises were getting worse or better. During a review of Resident 7's care plan titled, On Pentoxifylline for Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) Prophylaxis (prevent) - At Risk for Bruising and Bleeding Easily, dated 4/7/21, indicated interventions included were to monitor for development of bruise, bleeding from body orifice and careful handling and avoid injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 7 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm a.2. During a concurrent observation and interview with the Director of Nursing (DON) on 6/10/21 at 3:11 PM, Resident 7 was observed wearing a diaper. Upon removal of diaper, Resident 7's right and left buttock were observed with skin redness and breakdown and were covered with white ointment. The DON stated, Resident 7 developed MASD due to bowel incontinence. The DON added to prevent MASD, the resident should be kept clean, dry and wound should be open to air to prevent moisture. Residents Affected - Few During a review of Resident 7's care plan titled, Resident Has MASD of the Left and Right Buttock, dated 5/25/21, indicated interventions included were to monitor site, condition of MASD, signs and symptoms of infection, redness, drainage, and odor. During a record review and concurrent interview with the Registered Nurse Supervisor (RN 2) on 6/11/21 at 8:47 AM, she stated Resident 7's clinical record did not have a documented evidence the MASD was assessed and documented for measurement and appearance to determine if the MASD was getting worse or better. b. A review of the admission Record indicated Resident 15 was readmitted to the facility on [DATE]. Resident 15's diagnosis included chronic obstructive pulmonary disease (COPD, lung disease marked by permanent damage to tissues in the lungs, which makes breathing difficult). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/22/21, indicated Resident 15 had no memory and cognitive (ability to think and reason) impairment. Resident 15 required extensive assistance with bed mobility and was totally dependent on the staff for transfer, toilet use, and personal hygiene. During an observation on 6/10/21 at 3:26 PM, Resident 15 was observed receiving skin treatment to the sacrococcyx area from Licensed Vocational Nurse 1 (LVN 1). Resident 15's sacrococcyx area was observed bleeding. LVN 1 stated, Resident 15 developed MASD due to bowel incontinence and prolonged sitting in the chair while in the Dialysis (process of removing waste products and excess fluid from the body) Center. During a review of Resident 15's care plan titled, Resident Has On and Off Skin Breakdown (MASD) to Buttock and Sacrococcyx Area, dated 5/1/21, indicated interventions included were to monitor/document/reports as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. During a record review and concurrent interview with the Registered Nurse Supervisor (RN 2) on 6/10/21 at 3:47 PM, she stated there was no documented evidence Resident 15' MASD was assessed for the size, presence of bleeding or appearance to determine if it was getting worse or better with current treatment. A review of the facility's policy and procedure titled, Pressure Ulcer/Skin Breakdown, dated 10/2009, indicated the facility will routinely assess and document the condition of the resident's skin. Per facility wound and skin care program, for any signs and symptoms of irritation or breakdown, immediately report any signs of a developing pressure ulcer to the supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 8 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 offload (to suspend or take off pressure) left heel for one of three sampled residents (Resident 16) as indicated in the care plan and facility policy. Residents Affected - Few This deficient practice had the potential to result in the development of pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) and complications, which could affect resident's total well-being. Findings: A review of the admission Record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's medical diagnoses included high blood pressure and functional quadriplegia (complete immobility due to severe physical disability or frailty). A review of Resident 16's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 3/26/21 , indicated Resident 16 had severe cognitive impairment (mental action or process of acquiring knowledge and understanding) for daily decision making, with short and long term memory problems. Resident 16 was totally dependent with two person physical assist for bed mobility, transfers and personal hygiene. During a concurrent observation and interview with the facility's Case Manager/Licensed Vocational Nurse (CM), on 6/8/21 at 11:52 AM, Resident 16 was lying on her back, on an air loss mattress (special mattress that distributes air to relieve pressure). There was one pillow placed under Resident 16's lower extremities, with the left heel resting directly on the mattress. CM stated Resident 16's left heel should not be resting directly on the mattress because it could result in a bed sore. There was a sign observed located on the wall of Resident 16's room, which indicated to offload the resident's heels. CM stated, the sign was meant to remind the staff to offload Resident 16's heels to prevent pressure sores. During an observation on 6/08/21 at 12:33 PM, Resident 16 was in bed on her right side, one pillow under bilateral lower extremities and the left heel resting directly on the air loss mattress. During an observation on 6/9/21 at 9:30 AM, Resident 16 was lying in bed, turned to the right side with one pillow under both lower legs. Resident 16's right heel was offloaded and the left heel was resting directly on the mattress. During an observation on 6/9/21 at 2:42 PM, Resident 16 was lying on the right side with one pillow under bilateral lower extremities. Resident 16's right heel was offloaded and the left heel touching the mattress. During a concurrent observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 6/9/21 at 2:46 pm, LVN 6 verified Resident 16's heel was touching the mattress. LVN 6 stated Resident 16's heel should be elevated to prevent the development of bed sores. A review of Resident 16's plan of care titled, At Risk for Skin Breakdown, revised 3/9/21, indicated to assist the resident with turning and repositioning, careful handling and gentle positioning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 9 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 when turning or moving the resident. Level of Harm - Minimal harm or potential for actual harm A review of Resident 16's plan of care titled, Blanchable ( turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed) Redness to Left Heel, initiated 6/8/21, indicated to offload both heels when in bed. Residents Affected - Few A review of the facility's policy and procedures titled, Prevention of Pressure Ulcers revised October 2010, indicated that the most common site of a pressure ulcer (bed sore) is where the bone is near the surface of the body, including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. It indicated when Resident is in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 10 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve the highest level of range of motion (ROM, the full movement potential of a joint) for one of five sampled Residents (Resident 19) as indicated in the facility policy. This deficient practice had the potential for Resident 19 to experience a deterioration of the contracture (deformity from permanent shortening of muscle, tendon, or scar tissue) of the right hand. Findings: A review of the admission Record indicated Resident 19 was readmitted to the facility on [DATE]. Resident 19's diagnoses included hemiplegia (loss of muscle movement on one side of the body) and hemiparesis (weakness of one side of the body) following cerebrovascular disease (conditions caused by problems that affect the blood supply to the brain) affecting unspecified side and encephalopathy (disease, damage, or malfunction of the brain manifested by an altered mental state sometimes accompanied by physical changes). A review of Resident 19's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/29/21 indicated Resident 19's was independent with cognitive skills (thinking and memory skills) for daily decision making. The MDS indicated Resident 19 had functional limitations in range of motion in both lower extremities and one side of the upper extremity. Resident 19 required extensive assistance with dressing and was totally dependent on the staff for bed mobility, transfer, eating and personal hygiene. During an observation, on 6/08/21, at 11:09 AM, Resident 19 was unable to stretch open his fingers of his right hand from a closed fist position. During a concurrent observation and interview, on 6/9/21, at 1:35 PM, Restorative Nurse Assistant 1 (RNA, nursing aide program that helps residents maintain their function and joint mobility) placed a rolled-up wash towel within the grip of resident 19's right hand. Resident 19 stated his fingers have been closed shut for a long time. During a review of Resident 19's Physical Therapy (PT, profession with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function) Evaluation dated, 11/19/20, it indicated moderate ROM deficits with all extremities with active ROM. During a review of Resident 19's Discharge summary, dated [DATE], it indicated moderate to severe ROM deficits with all extremities especially with right upper extremity. During an interview, on 6/11/21, at 9:20 AM, PT 1 stated he should have recommended a splint be applied to Resident 19's right hand to prevent the contracture from deteriorating. During a review of the facility's policy and procedure (P&P) titled, Functional Impairment, dated 10/2010, P&P indicated in conjunction with the physician and staff, therapists will propose a rehabilitation of restorative care plan that provides an appropriate intensity, frequency and duration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 11 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 interventions to help achieve anticipated goals and expected outcomes efficiently using available resources. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 12 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - 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 supervise one of 24 sampled Residents (Resident 41) while eating lunch in the dining room as indicated in the facility policy and procedure. This deficient practice had the potential for the resident not to receive immediate care in an event of accidental aspiration (inhalation of food and fluid that could lead to choking or infection of the lungs). Findings: A review of the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnosis of senile degeneration of the brain (a progressive decline in memory and thought process due to aging). A review of the Minimum Data Set (MDS) a resident assessment and care-screening tool, dated 3/2/21, indicated Resident 41 was moderately impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 41 required supervision (oversight, encouragement or cuing) with one-person assistance with eating. During a dining observation on 6/8/21 at 12:45 PM, Resident 41 was observed eating lunch in the dining room without staff supervision. There were also four other residents sitting in the dining room who just completed eating lunch. During an interview with the Activity Director (AD) on 6/8/21 at 12:55 PM, AD stated she was not able to supervise and monitor the residents in the dining room because she had to take a Resident back to the room. AD stated there were no other staff who could monitor the Residents in the dining room. During an interview with Registered Nurse 2 (RN 2) on 6/11/21 at 9:40 AM, RN 2 stated Resident 41 should have been monitored while eating to prevent accidents and for staff to assist during emergency such as aspiration. A review of the policy and procedure (P&P) titled, Safety and Supervision of Residents,dated 12/2007, indicated the facility will strive to make the environment as free from accident hazard as possible. P&P indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions and ensuring that interventions are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 13 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 7 and 162) with a urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag) receive appropriate care, as indicated in the facility policy. Residents 7 and 162 were not assessed and monitored for signs and symptoms of urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). This deficient practice had the potential to result in delayed or no treatment for UTI, which could lead to sepsis (severe life threatening infection). Findings: a. A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7's diagnosis included chronic kidney disease (CKD, failure of the kidney to filter extra fluids and toxins) and history of UTI. A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/24/21, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills for daily decision making. Resident 7 required one person-extensive assistance with personal hygiene and toilet use. During an observation on 6/9/21 at 10:59 AM, Resident 7 was asleep with a urinary indwelling catheter bag hanging on the side of his bed. A review of the General Acute Care Hospital (GACH) record indicated on 5/20/21, Resident 7 was admitted to GACH with diagnoses of UTI, sepsis and dehydration ( a state of losing more fluids than one take in or fluid depleted). A review of the plan of care, dated 4/7/21, indicated Resident 7 was at risk for infection due to presence of Foley Catheter (urinary indwelling catheter). Resident 7's plan of care indicated interventions to be free of infection included were to assess and monitor resident for urine output, color, clarity, consistency and signs and symptoms of infection. During a record review and concurrent interview with Registered Nurse 2 (RN 2) on 6/10/21 at 12:41 PM, she stated there was no documented evidence Resident 7 was assessed and monitored for the signs and symptoms of infection and the urine output, clarity, color and consistency as indicated in the plan of care. b. A review of the admission Record indicated Resident 162 was admitted to the facility on [DATE]. Resident 162's diagnoses included neuropathic bladder (also known as neurogenic bladder, bladder does not empty or store urine properly due to neurological condition), hyperlipidemia (high level of fats in the blood), and hypertension (high blood pressure). A review of Resident 162's Minimum Data Set (MDS, a standardized assessment and care screening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 14 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tool), dated 6/4/21, indicated Resident 162's cognitive skills for daily decision making was independent. The MDS also indicated Resident 162 required extensive assistance from staff for bed mobility, transfer, toilet use and personal hygiene. The MDS also indicated Resident 162 has a urinary indwelling catheter. A review of the care plan, initiated on 6/2/21, indicated Resident 162 has an indwelling catheter for neurogenic bladder. The care plan interventions included were to monitor/record/report to Medical Doctor for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During a concurrent record review and interview with the Licensed Vocational Nurse 1 (LVN 1) on 6/9/21 at 8:29 AM, she stated there was no documentation that Resident 162 was assessed and monitored for signs and symptoms of UTI. During an interview on 6/10/21 at 12:20 PM, Director of Nursing (DON) stated staff should assess and monitor the signs and symptoms of UTI if the resident has a on foley catheter. DON also stated it was important to assess and monitor for signs and symptoms of UTI because Resident 162 was prone to infection. A review of the policy and procedure titled, Urinary Catheter Care, dated 10/2010, indicated to prevent catheter associated urinary tract infection, the facility will observe the resident for unusual urine appearance such as presence of blood and color), resident complaints of burning with urination, tenderness and/or pain in the urethral area and report findings to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 15 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. 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 nutritional care and services were provided to two of five sampled residents (Residents 7 and 25) as indicated in the physician's order, care plan, and/or facility policy by failing to: Residents Affected - Few a. Assess, identify the risk and evaluate Resident 7 who was recently readmitted from the General Acute Care Hospital (GACH) due to dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). There were no documented evidence of interventions such as monitoring signs and symptoms of dehydration and monitoring intake and output implemented. This deficient practice had the potential to result in the resident to have fluid loss not immediately replaced and lead to a recurrent dehydration. b. Provide Resident 25 fortified diet, as ordered by the physician and adequate assistance during meals, according to the resident's nutritional plan of care. These deficient practices placed Resident 25 at risk for weight loss. Findings: a. A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7's diagnoses included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins) and dementia (a progressive brain disorder that affects the thought process). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/24/21, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills for daily decision making. Resident 7 required extensive assistance with bed mobility and personal hygiene. Resident 7 was totally dependent with staff for transfer, dressing and toilet use. A review of the Medication Administration Record, dated, 6/2021, indicated to provide Resident 7 with a gastrostomy tube (GT, a tube inserted into the stomach to deliver nutritional formula, fluids and medications) feeding of Glucerna 1.2 at 65 cubic centimeters (cc) via pump with total 1430 cc and H20 ( water) flush 48 cc for 22 hours for a total of 10 cc ( GT feeding off at 9 AM to 11 AM). During a concurrent record review and interview with Licensed Vocational Nurse (LVN 2) on 6/08/21 at 9:32 AM, she stated, she was unable to obtain records of the intake and output of the Resident 7 in the new computerized system. During on observation on 6/09/21 at 8AM, Resident 7 was lying in bed asleep receiving Glucerna (nutritional formula) via GT. During a concurrent record review and interview with Registered Nurse 2 (RN 2) on 6/10/21 at 12:41 PM, GACH record, dated 5/20/21, indicated Resident 7 was admitted to the GACH with dehydration. RN 2 stated there was no care plan to address on how to prevent dehydration such as intake and output for daily monitoring. RN 2 stated there was no MD order to monitor for intake and output or laboratory test. RN 2 stated there was no documented evidence that Resident 7 was assessed and monitored for signs and symptoms of dehydration daily such as dry mouth/mucosa, skin turgor poor, confused, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 16 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 decreased urine output and laboratory test. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Resident Hydration and Prevention of Dehydration, dated 10/2011, indicated the facility will assess residents for signs and symptoms of dehydration. P& P indicated if potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. Laboratory test maybe ordered to assess hydration if intake and symptoms indicate possible significant hydration. Residents Affected - Few b. A review of the admission Record indicated Resident 25's was admitted to the facility on [DATE]. Resident 25's diagnoses included type 2 diabetes (sugar imbalance in the blood) and chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 25's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 4/5/21, indicated Resident 25 had severe cognitive impairment (mental action or process of acquiring knowledge and understanding) for daily decision making, with short and long term memory problems. Resident 25 required extensive assistance with one person physical assist for bed mobility and transfers. Resident 25 required extensive assistance with one person physical assist for dressing. (eating?) A review of Resident 25's Weights and Vitals Summary, indicated Resident 25 had a total weight loss of 9.46% from 1/6/21 to 6/4/21. A review of Resident 25's Clinical Nutrition Recommendations, dated 5/13/21, indicated to change diet to fortified diet (foods that have nutrients added to them, which were meant to improve nutrition and add health benefits), mechanical soft diet (softer texture, which includes chopped or ground meats raw fruits and vegetables used when there are problems with chewing and swallowing). A review of Resident 25's physician's orders, dated 5/13/21, indicated fortified mechanical soft diet. A review of Resident 25's plan of care, initiated 5/10/21, indicated that Resident 25 had a weight loss related to variable food intake. The care plan goal was for Resident 25 to consume 50-75% two or three meals per day. Interventions included were to supervise all meals, feed slowly, and document meal intake. On 6/8/21 at 12:53 PM, during a dining observation, Certified Nursing Assistant 3 ( CNA 3) set up Resident 25's lunch tray. CNA 3 exited the room when Resident 25 started eating her lunch. Resident 25 was observed to have stopped eating once CNA 3 exited the room. On 6/8/21 at 1:04 PM, during an observation, CNA 3 entered Resident 25's room and assisted Resident 25 with drinking juice. During a concurrent interview, CNA 3 stated that Resident 25 did not require assistance with eating, but that Resident 25 was forgetful and required reminders to eat. On 6/8/21 at 1:05 PM, a review of Resident 25's dietary card did not indicate fortified diet. Diet card indicated chopped meat, no added salt (NAS), but did not indicated fortified diet. On 6/9/21 at 4:56 PM, during a concurrent record review of Resident 25's medical record and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 17 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview with the facility's case manager/licensed vocational nurse (CM), CM stated, according to the plan of care, it indicated Resident 25 required assistance with eating. CM stated, Resident 25's plan of care indicated to feed the resident slowly. On 06/10/21 at 12:51 PM, during concurrent a review of Resident 25's dietary card and interview with the Dietary Supervisor (DS), DS verified Resident 25's dietary card did not indicate fortified diet. On 6/10/21 12:59 PM, during an interview, dietary aide 1 (DA 2) stated, he works in the tray line. DA 2 stated the tray line staff was responsible for updating the dietary cards when the nurses submit a slip with new dietary order. DA 2 stated, the tray line staff would refer to the resident's dietary card while the charge nurses on the floor were responsible for comparing the dietary card against the physician's orders to make sure the resident received the right diet. On 6/10/21 at 1:18 PM, during a concurrent record review and an interview with Licensed Vocational Nurse 1 (LVN 1), she stated, she was not aware what to look for when it came to fortified diet. LVN stated, it would be clearer for the staff if the dietary card specified a specific item to look for, such as, a soup or gravy. LVN 1 stated, she would check the tray to make sure that it was mechanical soft diet, NAS, no sweets, and would also check the consistency of the liquids. LVN 1 stated, she will verify with the director of nursing (DON) and come up with a better way of identifying the correct diet type, especially for fortified diets. A review of the Facility's Policy and Procedures titled, Nutrition Impaired/Unplanned Weight Loss- Clinical Protocol, revised December 2011, indicated the staff and the physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 18 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 failed to ensure one of three sampled residents (Resident 15) received two liters of oxygen as indicated in the physician's order and facility policy. Residents Affected - Few This deficient practice had the potential for Resident 15 to receive excessive amount of oxygen, which could lead to respiratory distress. Findings: A review of the admission Record indicated Resident 15 was readmitted to the facility on [DATE]. Resident 15's diagnosis included Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that results in difficulty breathing). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/22/21, indicated Resident 15 did not have a memory and cognitive ( ability to think and reason) impairment. Resident 15 required total assistance with one person for toilet use, transfer and personal hygiene. A review of the Resident 15 physician's order, dated 5/3/21, indicated to administer oxygen inhalation at two liters per minute via nasal cannula (a plastic tube inserted into the nostril used to deliver oxygen) continuously for shortness of breath (SOB) and or congestion three times a day. During an observation with the Licensed Vocational Nurse (LVN 2) on 6/8/21 at 10:12 AM, Resident 15 was receiving 2.5 liters per minute oxygen via nasal cannula. During an interview on 6/8/21 at 12:20 PM, the Director of Nursing (DON) stated, Resident 15 should have received 2 liters oxygen per minute if ordered by the physician. A review of the facility's undated policy and procedure, titled Oxygen Administration,/Respiratory Supply, indicated a licensed nurse or nursing staff should initiate to apply oxygen per order of primary care physician either via nasal cannula or mask with appropriate settings fans calibration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 19 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on observation, interview, and record review the facility failed to ensure the physician for one of 24 sampled residents (Resident 7) reviewed the resident's total program of care and documented a history and physical assessment that included medications and treatments within 72 hours of readmission to the facility. The facility readmitted Resident 7 on 5/24/2021 from the hospital after the resident was diagnosed with dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake of fluids), sepsis (severe blood infection) and acute renal failure (failure of the kidney to filter toxins and extra fluid in the body). This deficient practice had the potential for the resident and other potential residents not to receive the necessary care and treatments timely. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident 7 to the facility on 5/16/2014 and readmitted the resident on 5/24/2021, with diagnosis that included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins), dementia (a progressive brain disorder that affects the thought process). A review of Resident 7's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/24/2021, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills and daily decision making that required extensive assistance with one person assist on personal hygiene and toilet use. During an interview and a review of Resident 7's medical record on 6/8/2021 at 10:41 am conducted with Medical Record Director (MRD)/Licensed Vocational Nurse (LVN 2) indicated the following: a. Resident 7's General Acute Care Hospital 1 (GACH 1) record, indicated GACH 1 admitted the resident on 5/20/2021 with diagnoses of renal failure, urinary tract infection (UTI, infection in any part of the urinary system), sepsis (life-threatening response to infection that can lead to tissue damage, organ failure, and death), and dehydration (a state of losing more fluids than one take in or fluid depleted). b. Resident 7's History and Physical form contained a blank assessment and plan of care portion was blank, but the form was signed by a physician. c) No physician's order to monitor the resident for UTI-or monitor for signs and symptoms (s/s) of UTI and dehydration that included monitoring the labs and the intake and output every shift. In a concurrent interview with the LVN 2 on 6/8/2021 at 10:41 am, LVN 2 stated according g to the facility's policy and procedure the physician should assess, recommend treatments, and plan of care within 72 hours of admission or readmission to the facility. LVN 2 stated the history and physical assessment form was blank and not signed by the physician on 5/24/2021 when the resident was readmitted to the facility until the investigation on 6/8/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 20 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an observation on 6/9/2021 at 8 am, Resident 7 was lying in bed asleep receiving Glucerna (nutritional formula) via a gastrointestinal tube (a tube surgically inserted into the stomach used to deliver fluids and medications). Resident 7 observed with bruises on both hands. A review of the facility's policy and procedure, dated 8/2006, titled Physician Services, indicated the physician would participate in the resident's assessment, and care planning, monitoring changes in resident's medical status, providing consultation and treatments. The policy indicated the physician must perform an initial comprehensive visit for all newly admitted residents within 72 hours of admission and every 30 days thereafter. Event ID: Facility ID: 056117 If continuation sheet Page 21 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and take timely action on medication regimen review (MRR) irregularity and ensure the MRR was conducted for the month of 5/2021 for three of 24 sampled residents (Residents 56, 32 and 27) as indicated in the facility policy. a. For Resident 56, the physician failed to review and take timely action on MRR irregularity identified by the pharmacy consultant. The MRR, dated 3/2021 indicated for the physician to consider increasing metformin (used to treat high blood sugar levels caused by a type of diabetes mellitus [persistently high levels of sugar in the blood]) dose based on tolerance and renal function. The facility also failed to ensure Resident 56's medication regimen was reviewed for 5/2021. b. For Resident 32, the facility failed to ensure the resident's medication regimen for 5/2021 was reviewed. Resident 32 was taking two medications for the same condition. c. For Resident 27, the facility failed to ensure the resident's medication regimen was reviewed for 5/2021. These failures had the potential to result in possible use of unnecessary medications for these residents, excessive dose, adverse drug reaction to the medication, complication and decline in the residents' status. Findings: a. A review of the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included schizophrenia (mental disorder characterized by loss of contact with reality and the environment) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/16/21, indicated Resident 56 was cognitively intact (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 56 was independent for bed mobility and required supervision with locomotion off unit (how the resident moves to and returns from off-unit locations- areas set aside for dining, activities or treatment). A review of Resident 56's physician's order, dated 4/6/21 indicated Metformin 1000 milligrams (mg) one tablet by mouth one time a day for Diabetes. A review of Resident 56's physician's order, dated 4/6/21 indicated Metformin 850 mg, one tablet by mouth one time a day for Diabetes. A review of the Medication Regimen Review (MRR), dated 3/2021, indicated a pharmacy consultant's recommendation for the physician to evaluate increasing metformin dose based on tolerance and renal function. On 6/10/21 at 4:30 p.m., during a concurrent record review and interview with the case manager/Licensed Vocational Nurse (CM), she stated there was no documented evidence the MRR was done for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 22 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Resident 56 for 5/2021 and the MRR recommendation for the physician to evaluate increasing metformin dose based on tolerance and renal function was followed up. A review of the facility's policy and procedure titled, Medication Regimen Reviews, revised 4/2001 indicated the consultant pharmacist shall review the medication regimen of each resident at least monthly. Residents Affected - Few A review of the facility's policy and procedure titled, Medication Therapy, revised 4/2007, indicated upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review the individual's current medication regimen, to identify whether there is a clear indication for treating that individual with the medication, the dosage is appropriate, the frequency of administration and duration of use are appropriate; and potential or suspected side effects are present. The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequences are confirmed or suspected. b. A review of the admission Record printed indicated Resident 32 was admitted to the facility on [DATE]. Resident 32's diagnoses included Type 2 Diabetes Mellitus with diabetic neuropathy (type of nerve damage that can occur with diabetes, which most often damages the nerves in the legs and feet). A review of Resident 32's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/5/2020, indicated Resident 32 has intact cognitive skills for decision making. Resident 32 required supervision with bed mobility, walking in the room and limited assistance with transfer and toilet use. A review of Resident 32's physician's order, dated 9/28/20, indicated Cymbalta (used to treat depression [(mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety [excessive worry or fear] and for pain caused by nerve damage associated with diabetes) capsule delayed release particles 30 milligrams (mg), give one capsule by mouth one time a day for diabetic neuropathy related to type 2 diabetes mellitus. A review of Resident 32's physician's order, dated 9/28/20, indicated Gabapentin (used to relieve pain for certain conditions in the nervous system) capsule 300 mg, give one capsule by mouth every eight hours for Neuropathy. A review of Resident 32's care plan, dated 9/30/20, indicated Resident 32 has episodes of pain in both legs. Interventions included were to provide Cymbalta 30 mg daily and Neurontin 300 mg every eight hours as routine. During an interview on 6/10/2021 at 3:07 p.m., case manager (CM) stated a Medication Regimen Review was not conducted on 5/ 2021 because the pharmacist did not come to conduct an MRR in 5/2021. CM stated it was important to conduct a monthly MRR to ensure residents were appropriately cared for and receive the appropriate medications with the correct doses. A review of the Medication Administration Record (MAR), dated 6/2021, indicated Resident 32 received both Gabapentin and Cymbalta for neuropathy from 6/1/21 to 6/10/21. During an interview on 6/11/21 at 12:49 p.m., the Director of Nursing (DON) stated the pharmacy consultant did come in 5/2021, but did not do a comprehensive MRR because the pharmacist did not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 23 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm access to the electronic health records (EHR). DON stated the pharmacy consultant was only given access to the EHR on 6/9/2021. A review of the facility's policy and procedure titled, Medication Regimen Reviews, revised 4/2001 indicated the consultant Pharmacist shall review the medication regimen of each resident at least monthly. Residents Affected - Few c. A review of the admission Record printed indicated Resident 27 was readmitted to the facility on [DATE]. Resident 27's diagnoses included atrial fibrillation (irregular heart beat), depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic kidney disease (CKD, progressive loss in kidney function) A review of Resident 27's recapped physician's orders, dated 6/2021, indicated 17 active medications, which included, but not limited to the following, ordered on 3/30/21: 1. Remeron (antidepressant) tablet 45 milligrams (mg) one tablet by mouth at bedtime for depression 2. Xarelto (medication to treat and prevent blood clots) tablet 20 mg one tablet once a day for chronic atrial fibrillation. During an interview, on 6/11/21 at 9:36 a.m., case manager stated Resident 27's Medication Regimen Review was not done for 5/2021. During a review of Resident 27's clinical records, there was no documented evidence the Medication Regimen Review was not done for 5/2021. A review of the facility's policy and procedure titled, Medication Regimen Reviews, revised 4/2001 indicated the consultant Pharmacist shall review the medication regimen of each resident at least monthly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 24 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 monitor one of 24 sampled residents (Resident 7) for the side effects of Pentoxifylline ER (medication used to improve the symptoms of a certain blood flow problem in the legs/arms with side effects that included brushing and bleeding) as indicated in the plan of care. Residents Affected - Few This deficient practice had the potential for Resident 7 to bleed and experience other adverse (undesired) effects of the medication. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 5/16/2014 and readmitted on [DATE], with diagnoses of chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins), dementia (a progressive brain disorder that affects the thought process). A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/24/2021, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills and daily decision making that required extensive assistance with one person assist on personal hygiene and toilet use. During an observation on 6/8/2021 at 10:31 am, Resident 7 was observed asleep and with bruises on his hands. During a record review of Resident 7's medical record with Registered Nurse Supervisor (RN 2) on 6/10/2021 at 12:30 pm, indicated the following: 1. Resident 7's Physician order, dated 5/25/2021, indicated Resident 7 received Pentoxifylline ER (medication used to improve the symptoms of a certain blood flow problem in the legs/arms with side effects that included brushing and bleeding) tablet extended release 400 milligrams one tablet via gastrostomy tube (GT, tube placed directly into the stomach for long-term feeding), twice a day for prophylaxis (prevention). 2. Resident 7's Plan of care, dated 4/7/2021, indicated Resident 7 was at risk of bruising and bleeding easily related to the use of Pentoxifylline ER, the care plan indicated the nursing staff would monitor the resident for the development of bruise, bleeding from body orifice, monitor and report abnormal labs. In a concurrent interview on 6/10/2021 at 12:30 pm, RN 2 stated there was no documented evidence in the Medication Administration Record, Treatment Record and the Nursing Progress Notes that Resident 7 was monitored for bruising and bleeding while receiving Pentoxifylline ER. Reference https://www.rxlist.com/consumer_pentoxifylline_trental/drugs-condition.htm FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 25 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to monitor the behaviors for one of three sampled residents from a total sample of 24 residents (Resident 52) for the use of psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication as indicated in the resident's care plan and the facility's policy. This deficient practice had the potential for inadequate monitoring for effectiveness, dose adjustments and adverse (harmful) consequences to Resident 52. Findings: A review of Resident 25's Face Sheet (admission Record), indicated the facility admitted Resident 52 on 2/22/2021 with diagnoses of major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), diabetes (a condition that affects the way the body processes blood sugar), and hyperlipidemia (high level of fats in the blood). A review of Resident 52's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/11/2021, indicated Resident 52 had intact cognitive response. MDS indicated Resident 52 did not have any behavioral or mood symptoms and required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During a review of Resident 52's Care Plan untitled, initiated 5/18/21, indicated Resident 52 was on Zoloft for major depressive disorder m/b verbalization of sadness and the interventions were to monitor or to document for the side effects and effectiveness. A review of Resident 52's Physician's order dated 6/1/2021, indicated for the resident to receive Zoloft (medication to treat schizophrenia [serious mental disorder in which people interpret reality abnormally]) tablet 100 milligram (mg, a unit of measurement) by mouth one time a day for depression manifested by (m/b) verbalization of loneliness. During an interview on 6/8/2021 at 2:12 pm, the Case Manager (CM 1) stated that there was no behavior monitoring ordered by the physician. A review of the facility's Antipsychotic Medication Use policy and procedure with a revised date of April 2007, indicated antipsychotic medication therapy should be used only when it was necessary to treat a specific condition and the physician and the facility staff would gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks. The policy indicated the nursing staff would document in detail an individual's target symptom (s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 26 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to provide safe storage of medication for one of 24 sampled residents (Resident 16). This deficient practice had the potential for Resident 16 to receive expired or non-potent medication. Findings: A review of Resident 16's admission Record indicated the facility admitted the resident on 10/31/2010 with diagnoses of ataxia (the loss of full control of bodily movements) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it, a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and functional quadriplegia (complete inability to move due to severe disability). A review of Resident 16's History and Physical (H&P) Examination dated 3/25/2021, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 3/26/2021, the MDS indicated the resident was severely impaired with her cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was total dependent (needs full staff assistance) with bed mobility (ability to move easily), eating and on personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 16's Medication Administration Record (MAR) dated 3/2021, the MAR indicated the Lactulose (stool softener) was given on 3/1/2021 and 3/7/2021. A review of Resident 16's Physician Telephone Order dated 5/4/2021, indicated Lactulose 20 gram (gm, unit of measurement) per 30 milliliters (ml, unit of measurement) administer 30 cubic centimeter (CC, unit of measurement same with ml) via enteral tube (food or medication taken through a tube that goes directly to the stomach or small intestine) as needed two (2) times a day for constipation (person passes less than three bowel movements a week, or has difficult bowel movements), was on 9/16/2020 and was discontinued on 5/4/2021. During observation of the facility's Medication Cart 2 (MC 2) and interview with the Licensed Vocational Nurse 4 (LVN 4) on 6/10/2021 at 12:45 pm, the MC 2 contained Resident 16's one bottle of Enulose (lactulose) 10 gm per 15 ml with date delivered on 3/2/2021. LVN 4 sated the bottle was more than half way empty and there was no date labeled of when it was initially opened and used. During the concurrent interview, LVN 4 stated it was important to indicate in the medication bottle for when it was opened and first used to determine if when to discard and replace the medication bottle. In addition, LVN 4 stated it was important to make sure residents did not get expired medications or it was not effective anymore since it was opened for a long period of time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 27 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During concurrent interview with Director of Staff Development (DSD) on 4/11/2021 at 8 am and review of the facility's policy for Storage of Medications revised 4/2007, the DSD stated the policy indicated the nursing staff was responsible for maintaining medication storage in a safe manner and facility shall not use discontinued and outdated drugs. DSD stated they followed the policy by ensuring the label of medication when received from pharmacy indicated the expiration date and for the licensed nurse to label in the bottle the date of when the medication bottle was first opened and used. The DSD stated if the medication was discontinued, the licensed nurses were to remove resident's information and the medication must be discarded in the appropriate bin. DSD stated it was important to indicate the date the medication bottle was opened so all licensed nurses accessing the medication knows when it should be discarded and to ensure residents are getting potent medication (effective medication). Event ID: Facility ID: 056117 If continuation sheet Page 28 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide sufficient dietetic service oversight when dietetic service supervisor (DS) was not working full time while registered dietitian worked on a consulting basis, as evidenced by lapses in the delivery of food services associated with staff competency (Cross Reference F802), therapeutic diet accuracy and following of puree recipes (Cross Reference F803 and F808), and food safety and sanitation (Cross Reference F812). This deficient practice could result in compromising the safety and nutritional status of residents through the potential transmission of foodborne illness, incorrect serving of physician ordered therapeutic diets, and/or decreased nutritional intake due to poor resident acceptance of pureed diets. Findings: During the annual recertification survey from 6/8/2021 to 6/10/2021, multiple issues surrounding the delivery of dietetic services were unmet in relation to: 1) The oversight of food safety, sanitation, and storage of food in the kitchen (cross reference F812). 2) The evaluation of dietary staff competency (cross reference F802). 3) The overall evaluation of food production in relation to therapeutic diets and puree diets (cross reference

F803 and F808). During an interview with the dietary manager (DM) on 6/8/2021 at 8:38 am, regarding kitchen supervision, DM stated the dietary supervisor (DS) was in charge of supervising kitchen staffs and she was in charge of meetings and paperwork. A review of the kitchen manager and supervisor credentials indicated that DS had a certification for food safety manager through national registry of food safety professionals, effective from 5/7/2019 to 5/7/2024. However, the DS did not have a certification from an accredited (officially authorized) dietetic service supervisor program or an accredited certified dietary manager program. The DM had the certificate of completion from Los Angeles City College for dietetic Service supervisor since 6/7/1991. During an interview with the DS on 6/8/2021 at 8:56 am, regarding DS role and responsibility of DS, DS stated he was a chef who worked the cook position here, but he was in charge of supervising kitchen staffs and he worked about 38-40 hours a week from Monday to Thursday. During an interview with the DM on 6/8/2021 at 10:23 am, regarding working status and hours on site, DM stated she worked full time for 32-36 hours a week, but she could not provide her hours as she did not clock in and out. During an interview with the Administrator on 6/8/2021 at 10:25 a.m., Administrator stated managers did not clock in and out, but he had written work hour logs from the DM for payroll for 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 29 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm A review of DM written work hour log indicated DM working hours were from 2 pm to 5pm, or 5:30 pm for four days a week. The log indicated January 2021, DM worked a total of 34 hours a month. In February 2021, DM worked a total of 52 hours a month. In March 2021, DM worked a total of 62.5 hours a month. In April 2021, DM worked a total of 51 hours a month. No log submitted for May or June 2021 yet according to the Administrator. Residents Affected - Few An interview with the DM on 6/8/2021 at 10:50 am, to clarify her working status, DM stated she confirmed she only worked about 3-3.5 hours a day for four days a week and she had been working like this for about three years now. DM stated she knew kitchen needed to have a full-time dietetic service supervisor credentialed through an approved program when registered dietitian was only working on a consulting basis and not full time. DM stated RD consulted about one day a week. A review of the DM's employee file indicated DM had been hired to work at the facility since December 1, 2015. A review of facility's undated job description for Dietary Supervisor, indicated Dietary supervisor must be a graduate of a state approved course providing 90 or more hours of classroom instruction in foodservice management, and has experience as a supervisor in a health care institution with consultation from a dietitian. One of the duties of the dietary supervisor included: develops and maintains sanitary practices in the Dietary Department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 30 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: Residents Affected - Many a. Diet Aide 1 (DA 1) and [NAME] 1 did not know sanitary food storage policy related to storing scoop inside the bulk container(cross reference F812). b. Dishwasher 1 (DW 1) and DA 1 did not know the proper sanitizer test strip to use for the dish machine sanitizer and quaternary ammonium (QUAT, a type of sanitizing solution) sanitizer. DA 1 and dietary supervisor (DS) did not know the concentration strength of the quaternary ammonium sanitizer. c. [NAME] 2 did not follow standardized recipes when preparing pureed diet and was not evaluated for competency related to puree preparation (cross reference F803). d. Dietary manager (DM) and dietary supervisor (DS) did not have documented routine staff competency evaluation to ensure all kitchen staff were competent in their job related duties. These deficient practices had the potential to result in unsafe and unsanitary food production that could place 59 out of 68 residents in the facility who received food at risk for foodborne illnesses, and making puree food without following recipes had the potential to result in decreased nutrient intakes for 7 out of 68 residents who received the pureed diet. Findings: a. During an observation and a concurrent interview with DA 1 on 6/8/2021 at 7:58 am, there was a scoop inside the salt container and a scoop inside the thickener container. DA 1 stated she did not know if scoops could be stored in the container, DA 1 stated the cook would know. During an interview with [NAME] 1 on 6/8/2021 at 7:59 am, [NAME] 1 stated scoop should not be stored inside the bulk container; however, [NAME] 1 stated they always kept scoop inside the thickener container so the measuring scoop would not get lost. b. During an observation on 6/8/2021 at 8:23 am, to check dish machine sanitizer concentration when requested, observed DW 1 attempted to use the QUAT sanitizer test strip to test the sanitizer concentration in the dishmachine. DW 2 stopped DW 1 and provided another test strip. DW 2 stated he should have used a chlorine test strip to test the dish machine sanitizer and not the QUAT test strip. During an interview with DW 1 using DW 2 as interpreter on 6/8/2021 at 8:24 am, DW 1 stated he was trained by another dishwasher, but not by the DM or the DS. During an observation on QUAT sanitizer concentration check on 6/8/2021 at 9:06 am, observed DA 1 used the chlorine sanitizer strip to check QUAT sanitizer inside the red bucket and the test strip did not change color. During an interview with the DS on 6/8/2021 at 9:08 am, DS stated DA 1 should have used the QUAT sanitizer test strip. After the correct test strip was used, the strip showed the sanitizer was at 100 parts per million (PPM- unit of concentration measurement). DS and DA 1 both stated 100 ppm would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 31 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 be acceptable for the QUAT sanitizer. Level of Harm - Minimal harm or potential for actual harm During an interview with the DM on 6/8/2021 at 9:09 am, DM stated QUAT solution concentration should be at least 200 ppm. Residents Affected - Many A review of facility's policy and procedure titled Sanitization and infection control: Sanitizing equipment and surfaces with quaternary ammonium (QUAT) sanitizer, dated 2018, indicated 2. Staff will check for appropriate QUAT level by inserting a QUAT test strip into the bucket of solution. 3. Testing strips can range between 150 - 400 PPM, or per manufacturer's guidelines. c. During an observation and a concurrent interview with the [NAME] 2 on 6/9/2021 at 8:40 am, observed two pans of puree-like food products with a layer of water floating on top of the pans on the stove. [NAME] 2 stated the pans were pureed pork and pureed green beans for lunch. [NAME] 2 stated he usually make puree early in the morning then reheat it later closer to lunch time. [NAME] 2 stated he did not make puree foods from today's regular entrée barbeque (BBQ) pork and sea greens, he used 5 pounds (lbs) of ground pork with four to five cups of water to puree six servings of pureed pork. [NAME] 2 stated he did the same for puree green beans, he added water to the green bean during pureeing then he would add thickener to it when puree green bean was heated. (cross reference 803) d. During a concurrent in-service record review and interview with the dietary manager (DM) on 6/9/2021 at 9:31 am, DM stated there was no in-service documentation on puree diet preparation or proper sanitizer test strip or acceptable sanitizer concentration in the in-service binder for the year. During an interview with the DM on 6/8/2021 at 9:35 am, regarding staff competency evaluation, DM stated they did not perform competency verification for staff. DM stated facility had new hire orientation checklist form, but no annual competency verification system in place. During an interview with the DS who assisted DM for kitchen supervisor on 6/8/2021 at 9:38 a.m, DS stated he did not do a competency evaluation for staff annually and there were no check lists to evaluate staff skills to ensure they were following food safety and sanitation procedures. DS stated there were no recent new hires, and stated he did not use orientation checklist form. A review of facility's employee orientation checklist titled Checklist of areas to be covered and competence verified, dated 2018, indicated area to be covered and competence verified should include Food protection, personal hygiene, cleanliness, and general habit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 32 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure puree diet (composed of food of a pasty consistency: smooth, with no lumps or pips), was prepared according to the menus and standardized recipes when: a. [NAME] 2 prepared pureed ground pork and pureed green beans prior to regular lunch entrées were made and without following puree recipes. b. Puree vegetables texture on the test tray tasted gritty with small chunks and not smooth. These deficient practices had the potential to result in decreased puree food quality, different tastes from the regular menu entrée and had the potential to result in decreased food intakes for residents who were on a pureed diet. Findings: a. During an observation and concurrent interview with the [NAME] 2 on 6/9/2021 at 8:40 am, observed two pans of puree-like food products with a layer of water floating on top of the pan on the stove. [NAME] 2 stated the pans were pureed pork and pureed green beans for lunch. [NAME] 2 stated he usually made puree early in the morning then reheat it later closer to lunch time. [NAME] 2 stated he did not make puree foods on 6/9/2021 regular entrée barbeque (BBQ) pork and sea greens, he stated he used five pounds (lbs) of ground pork with four to five cups of water to puree six servings of pureed pork. [NAME] 2 stated he did the same for puree green beans, he added water to the green bean during pureeing then he would add thickener to it when puree green bean was heated. During an interview with the [NAME] 2 on 6/9/2021 at 8:45 am, [NAME] 2 stated he had been cooking for 14 years and this was how he always made pureed foods. [NAME] 2 stated he was trained when he first started working at the facility, but kitchen managers did not train him again on puree food preparation. During an interview with the Dietary Manager (DM) on 6/9/2021 at 9:31 am, regarding pureed food preparation in-services, DM stated there was no puree in-service documentation. At 9:34 am, DM stated the expectation for cooks would be making puree from the regular entrée and puree entrée with liquids from the cooked meats or vegetables, not adding water to puree. A review of facility's undated recipe titled BBQ Pork Rib, indicated puree would be made by placing cooked BBQ pork rib portions needed into food processor and for every 10 serving, 10 pieces of 3.5 ounces of BBQ pork ribs would be used. b. During a test tray sampling with the DM on 6/9/2021 at 12:40 pm, the pureed green bean tasted gritty with small chunks inside that required some chewing before swallowing. During an interview with the DM on 6/9/2021 tat 12: 41 pm, DM stated she could also taste small chunks inside and stated green beans should be pureed longer to a smoother texture. A review of facility's undated recipe titled Seas Greens, which was the vegetable on the 6/9/2021 lunch menu, indicated to Remove portions needed from regular recipe; drain and reserve cooking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 33 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm liquid. Place drained portions into a food processor Process until smooth. The recipe also indicated any variety of greens may be substituted in this recipe . example: collard, turnip, spinach, mustard green, kale, chard. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 34 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food brought to resident by family members were appropriate, palatable (pleasant to taste), at a safe temperature, and was in accordance to resident's therapeutic (meal plan that controls the intake of certain food or nutrients for the treatment of a medical condition) diet for one of three sampled residents (Resident 51) as indicated in the physician's order, care plan and facility policy. Residents Affected - Few Findings: A review of the Admissions Record indicated Resident 51 was admitted to the facility on [DATE]. Resident 51's diagnosis included Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 51's Nutrition Assessment, dated 5/4/2021, indicated a diet order of mechanical soft finely chopped (diet that involves only foods physically soft, with the goal of reducing or eliminating the need to chew the food) with thin liquids (liquids that become thin at room temperature). A review of Resident 51's care plan initiated on 5/10/2021 and revised 6/10/2021, indicated the risk for nutritional problem related to diet restrictions and recent stroke. Interventions included were to provide and serve diet as ordered, which was mechanical soft, no concentrated sweets (NCS) finely chopped. During observation and interview on 6/8/2021 at 10:40 a.m., Resident 51 stated, he does not like and does not eat the food at the facility. Resident 51 stated, he preferred food brought by the family member. Resident 51 was observed with a Ziploc bag with two round items wrapped in yellow paper and a package of crackers. Resident 51 stated, these were brought by the family member who comes to visit and brings food every two days. Resident 51 had a jar of peanut butter and bread at bedside. Resident 51 stated he eats the peanut butter and bread for his snack. During an observation and interview on 6/10/21 at 12:56 p.m., Resident 51 was observed with a facility lunch tray at bedside. Resident 51 stated he will not eat any of the food on the tray except for the coffee. Resident 51 stated has a container of food with white rice , which the family member brought from home yesterday. During an interview and record review with Case Manger (CM) on 06/11/21 9 AM, she stated there were no documentation in the clinical record or care plan to indicate food brought by Resident 51's family member were appropriate according to the physician's order. During an interview with the Director of Nursing (DON) on 6/11/21 at 1:10 PM, DON stated there was were no documentation in the clinical record or care plan indicating Resident 51's family member was educated about bringing in food in accordance to the physician's order. A review of the facility policy and procedure (P&P) titled, Foods Brought by Family/Visitors revised 12/2008, indicated family members should inform nursing staff of their desire to bring foods into the facility. P&P also stated the Director or a Nurse Supervisor should assure food is not in conflict with the resident's prescribed diet plan. P&P indicated the Dietitian will counsel residents or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 35 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm families about requests that conflict with residents' dietary restrictions and whenever diets cannot be liberalized. It also indicated the Dietitian or a nurse will document any such discussions in the residents' medical records. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 36 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 27) was served the food preferences listed on Resident 27's lunch tray card. This deficient practice had the potential to result in decreased meal satisfaction and consumption and negatively affect Resident 27 nutritional status. Findings: A review of Resident 27's care plan initiated on 3/31/2021, indicated the concern identified was Alteration in nutrition status, and the approach included Adhere to dietary preferences and restrictions and the responsible disciplines included dietary and nursing. A review of Resident 27's clinical record under Nutrition Note, and Nutrition Assessment, indicated food preference was reviewed and documented on 4/2/2021 and 6/8/2021. During an observation on 6/8/2021 at 12:50 pm, Resident 27's tray on the bedside table had mashed potatoes, ground meats with gravy, mixed vegetables, milk, and a cup of chocolate colored beverage labeled Hi Pro. During an interview with Resident 27 on 6/8/2021 at 12:51 pm, Resident 27 stated she did not like the food and would not eat it. Resdient 27 stated she would only drink the milk and she disliked the chocolate beverage that labeled Hi Pro. Resident 27 stated she kept getting that and she never drank it. A review of Resident 27's lunch tray card preference indicated Dislike: No Mashed potatoes, No Rice, No Pizza, Mexican Food, and likes Ice Cream. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/8/2021 at 1:02 pm, LVN 1 stated she checked lunch meal trays to ensure diet matches the order but would also check for preferences listed on the meal card. LVN 1 stated Resident 27 received mashed potato even though it was listed as a dislike, and Resident 27 did not receive ice cream when it was listed as liked. LVN 1 stated she did not see that during tray check and stated Resident 27 just did not like to eat in general. During an interview with the Dietary Manager (DM) on 6/9/2021 at 10:04 am, DM stated she was responsible to obtain resident's food preferences for all residents. DM stated she tried to do it in three to five days within resident's admission, and would update preferences quarterly, annually, or as needed. During an interview on 6/9/2021 at 11:00 am, LVN 2 stated Resident 27's medical record had documentation from the dietary staff was on 4/2/2021 and 6/8/2021, and stated there was no other documentation from the time Resident 27 readmission on [DATE] to 6/8/2021. A review of facility's policy and procedure titled Nutrition care - resident/ patient food preferences, dated 2018, indicated 1. The director of Food and Nutrition Services or designee would visit resident/ patient within 24-48 hours of admission to determine food preferences, and 3. The food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 37 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 preferences should be minimally reviewed quarterly with the resident/patient by the DSS (dietetic service supervisor) and as needed with a clinical risk. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 38 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician for two of 24 sampled residents (Resident 27 and Resident 45). This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss. Findings: a.A review of Resident 27's meal tray card indicated Resident 27 was on a fortified mechanical soft NCS (no concentrated sweets) diet. During an observation on 6/8/2021 at 12:50 pm, Resident 27's tray on the bedside table had mashed potatoes, ground meats with gravy, mixed vegetables, milk, and a cup of chocolate milk labeled Hi Pro. A review of facility's lunch spreadsheet (food portion serving guidelines) indicated to provide Super Soup 6 oz for fortified diets. During an interview with Resident 27 on 6/8/2021 at 12:55 pm, Resident 27 stated she did not receive soup at lunch. During an interview with the Dietary Manager (DM) on 6/8/2021 at 1:05 pm, DM stated if the spreadsheet indicated to provide Super Soup, kitchen staff should put Super Soup on the tray for the fortified diets. During an interview with the cook (Cook 1) on 6/8/2021 at 1:07 pm, [NAME] 1 stated she did not know what Super Soup was and never made it before. During an interview with the dietary supervisor (DS) who oversaw food production on 6/8/2021 at 2:33 pm, DS stated they changed menu system about one month ago and he forgot to bring the Super Soup recipe to the cooks. DS stated he did not have documented in-service training when changing to the new menu and spreadsheet system. b. During an observation on 6/9/2021 at 12:29 pm, Resident 47's tray card on the tray indicated Resident 47 was on a Fortified mechanical soft NAS (no added salt), diet but there was no soup on the tray. During an interview with Certified Nursing Assistant 2 (CNA 2) on 6/9/2021 at 12:30 pm, CNA 2 stated she did not see a soup on the tray. CNA 2 stated she was not aware soup should be provided with fortified diet trays. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/9/2021 at 12:33 pm, LVN 1 stated she did not know fortified diet required to have soup on the tray during tray check, so she did not know Resident 47 was missing a soup. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 39 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. One Diet Aide 1 (DA 1) and one cook (Cook 3) did not wear hair covering that covered hair completely in the food preparation area. b. Equipment, floor, drains and shelving in the food storage and food preparation area were dirty. Chemicals were stored directly on the dirty floor and one detergent without covering. c. Several food items were not dated, labeled, and sealed after opened in the food preparation area, walk-in freezer, and dry storage area. Grape Jelly were stored at room temperature after opened. Some breads in the dry storage area were past best by dates and two can goods were dented. d. Scoops stored inside bulk thickener container and salt container. e. DA 2 did not wash hands after discarding trash when returning to the kitchen and entered walk-in refrigerator to put away delivery. f. Resident meal trays, muffin tins and cooking pans were not air dried after washing and stacked wet. g. Personal water and keys were stored on the shelf in the food preparation area. h. Reach-in freezer did not have a thermometer and there were several gaps on the June 2021 temperature log. i. Ice machine internal compartments were dirty. j. Large amount of ice buildup inside the walk-in freezer ceiling, wall, condenser, and on the food box. k. Egg salad, leftover meats and leftover pasta in the walk-in refrigerator were not monitored for safe cool down process (hot food cooled down within a certain time frame to prevent harmful bacterial growth). l. Raw salmon stored on top and next to ready to eat foods in the walk-in refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 59 out of 68 medically compromised residents who received food and ice from the kitchen. Findings: a. During an observation on 6/8/2021 at 7:52 am, DA 1 was wearing a baseball cap in the food preparation area and the hair below the cap were not covered with a hairnet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 40 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 6/8/2021 at 7:52 am with DA 1 with translation assistance from DA 2, DA 2 stated DA 1 forgot to wear a hairnet and stated he should be wearing hairnet underneath the baseball cap. During a concurrent observation and interview with [NAME] 3 on 6/9/2021 at 2:30 pm, [NAME] 3 was wearing a cap without a hairnet underneath and hair was extending out under the cap. [NAME] 3 stated he had forgotten to put on a hairnet. During an interview with the dietary manager (DM) on 6/9/2021 at 2:31 pm, DM stated staff should wear a hairnet underneath the cap to cover all hair. b. During a kitchen tour observation on 6/8/2021 at 7:54 am, the can opener blade was dirty. There was grime build up on the can opener blade attachment, around the base and the chute cavity. During an interview with [NAME] 1 on 6/8/21 at 7:55 am, [NAME] 1 stated they washed can opener in the afternoon, but it should be cleaned as needed as well. On 6/8/2021 at 7:56 am, observed the counter shelf above food preparation counter where menu was place was very dusty. At 8:05 am., observed there were spills and splatter makes on the cart where standing mixer was stored. The blender next to the mixer had a dirty base. On 6/8/2021 at 8:13 am, observed the drain under coffee machine was dirty with debris and [NAME] build up on the metal cover and around the drain. On 6/8/2021 at 8:18am, observed five chemical containers stored directly on the floor in the dishwashing area. On 6/8/2021 at 8:20 am, observed the floor under dishwashing machine was dirty. There was [NAME] and trash in the dishwashing area. An interview with the dishwasher (DW 2) on 6/8/2021 at 8:21 am, DW 2 stated they sweep the floor after each shift and the chemicals were on the floor because they were waiting on the metal shelving to be ordered for storage. On 6/8/2021 at 8:28 am, there were two fans in the kitchen by the dishwashing area. One on the floor and one on the shelf above food preparation counter, both fan covers were dusty. The trays storing cups next to the fan was dusty and sticky to touch. During an interview with Dietary Manager (DM) on 6/8/2021 at 8:33 am, DM stated fans should be cleaned at least monthly, but it should be cleaned more often as needed. On 6/8/2021 at 8:36 am, observed one container of laundry detergent was opened without a lid under the three-compartment sink. An interview with DM on 6/8/2021 at 8:38 a.m., DM stated the chemical was pot and pan detergent. Staff reused the laundry detergent container to fill pot and pan detergent. DM Stated they should not use laundry detergent container for refill and the detergent should be covered. During a concurrent observation and interview with the DM on 6/8/2021 at 8:41 am, observed black grease build up on the back splash of the stove and along the grill. There was some grease build up on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 41 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 the hood. DM stated stove, grill and hood should be cleaned weekly. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with the DM on 6/8/2021 at 8:52 am, observed food like debris, dusts and [NAME] build up under the shelves inside the dry storeroom. DM stated she could see it was dirty under the shelves. Residents Affected - Many During an interview with the DM on 6/8/2021 at 9:17 am, regarding kitchen cleanliness and cleaning schedule, DM provided a copy of the daily cleaning schedule and the schedule were not signed off by kitchen staff. DM stated staff should sign off the cleaning log after completing their assigned task. During a concurrent observation and interview with the DM on 6/8/2021 at 10:06 am, observed walk-in refrigerator fan cover was dusty on the condenser and the ceiling by the condenser was very dusty. DM Stated it should be cleaned by the kitchen staff every three months. A review of facility's undated policy titled Daily cleaning schedule, indicated can opener, floor drains, ranges should be cleaned daily, and floor swept three times daily. A review of facility's policy Routine schedule for cleaning designated kitchen area indicated hoods and storeroom would be cleaned weekly and ceiling should be cleaned monthly. There was no instruction on walk in refrigerator condenser cleaning and fan cover cleaning indicated on the cleaning schedule. c. During a concurrent observation and interview with [NAME] 1 on 6/8/2021 at 7:57 am, observed several spices including red hot seasoning, siracha, rotisserie chicken seasoning, fajita seasoning, whole bay leaves, paprika, oregano, low sodium beef broth and black pepper on the food preparation counter were not dated to indicated when spices were received or opened, or when to use it by. [NAME] 1 stated their practice was to date item upon receive and when it was opened. During a concurrent observation and interview with [NAME] 1 on 6/8/2021 at 8 am, observed two opened bottles of grape jelly on the food preparation counter shelf. The instruction on the bottle indicated to refrigerate after opened. [NAME] 1 stated they always kept grape jelly outside at room temperature, she did not know it required refrigeration after opened. During an observation on 6/8/2021 at 8:04 am, observed one container of confectioner sugar left opened and not sealed, there's also not a date on the sugar container. There was a bottle of burgundy cooking wine next to the sugar that did not have a date indicating when it was received, opened or to use it by. On 6/8/2021 at 8:12 am, there was one box of hot cocoa, one box of Sanka instant coffee, one box of tea tag without dates indicating when they were received, opened or to use it by. On 6/8/2021 at 8:45 am, observed one bulk container of creamer with a broken lid that did not cover the creamer completely. During an interview on 6/8/2021 at 8:46 am, with the DM regarding food storage process, DM stated all foods should be dated upon receive and when opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 42 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 6/8/2021 at 8:49 am, in the dry storage area, observed one crushed tomato can and one applesauce can were dented on the shelf. On 6/8/2021 at 8:53 a.m. in the dry storage area, observed one box of grape jelly, one box of syrup and five bottle of vanilla blends, two boxes of potatoes, one bulk bin of flour and one box of dry pasta do not have a date indicating when they were received. On 6/8/2021 at 8:59 am, observed one bag of hamburger buns with best by date of 6/7/2021 and two bags of white bread with best by date 6/7/2021. Dietary supervisor (DS 2) who was assisting the DM stated foods should be rotated and discarded as needed during delivery and restock time. On 6/8/2021 at 9:03 am, observed one ice cream not covered in the reach-in freezer, and there were two trays of ice cream without dates. During a concurrent observation and interview with DM on 6/8/21 at 10:05 a.m, there was one tray of yogurt and dessert bowls without dates and no label indicating what food was in the dessert bowls inside the walk-in refrigerator. DM stated foods should be labeled to show the content. On 6/8/2021 at 10:09 am, observed cheeses, waffles and tator totes in the walk-in freezer do not have dates on the products. One bag of frozen corn was not sealed after opened and was exposed to the air inside the walk-in freezer. A review of facility's policy and procedure titled Sanitation and infection control - canned and dry good storage, indicated all the food and nonfood items would be stored properly, and all opened food items would have an open date and used-by-date per manufacturer's guidelines. The procedure indicated canned food items should be routinely inspected for damage such as dented, bulging or leaking cans. A review of facility's policy and procedure titled Employee orientation checklist, dated 2018, indicated staff should verify for competence on food protection to ensure all foods stored only in kitchen areas and in properly closed containers, dated and sated as per policy. d. During an observation and a concurrent interview with DA 1 on 6/8/2021 at 7:58 am, there was a scoop inside the salt container and a scoop inside a container labeled as thickener. DA stated she did not know if scoops could be stored in the container, DA 1 stated cook would know. An interview with [NAME] 1 on 6/8/2021 at 7:59 am, [NAME] 1 stated scoop should not be stored inside the bulk container; however, [NAME] 1 stated they kept scoop inside the thickener container so scoops would not get lost. A review of facility's policy and procedure titled Sanitation and infection control - canned and dry good storage, indicated all the food and nonfood items would be stored properly. The policy indicated all opened food items would have an open date and used-by-date per manufacturer's guidelines. The procedure indicated scoops were to be stored in a separate area, not inside food containers, and need to be cleaned each time they are used. e. During an observation on 6/8/2021 8:08 am, diet aide 2 (DA 2) entered kitchen from the side door and walked directly into the walk-in refrigerator. DA 2 did not wash his hands when returned to the kitchen, and DA 2 came out of the walk-in refrigerator with a watermelon in his hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 43 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with the DA 2 on 6/8/2021 at 8:09 am, DA 2 stated he went outside to discard empty boxes after putting delivery away. DA 2 stated he should have wash hands after he returned to the kitchen, but he forgot. A review of facility's undated policy and procedure titled Handwashing, indicated Dietetic department personnel should wash their hands before starting work .after handling garbage. f. During a concurrent observation and interview with [NAME] 1 on 6/8/2021 at 8:14 am, there were five muffin tins stacked together under the food preparation counter. The muffin tins were wet with water still in between each muffin tins. Two of the trays also had food-like debris stuck on the muffin tin. [NAME] 1 stated the trays should not be stacked when they were still wet. [NAME] 1 also stated those muffin tins were not washed thoroughly and should be washed again. During an observation on 6/8/2021 at 8:15 am, there were a stack of resident's food trays on the cart by the steam table counter. The trays were wet with water still in between each tray. During an interview with dishwasher 2 (DW 2) on 6/8/2021 at 8:16 am, DW 2 stated they should air dry everything that were washed for about three to four minutes before stacking. DW 2 stated residents food trays were washed last night and not from this breakfast, he was not sure why water would still be on the trays. A review of facility's policy and procedure titled Sanitation and infection control - dishwashing procedures, dated 2018, indicated allow racks of dishes/ trays/ utensils to air dry. If drying space is not ample for dishes to air dry, use utility carts Do not rack and stack wet dishes or trays. Reference According to the 2017 Federal FDA Food Code section 4-901.11 titled Equipment and Utensils, Air-Drying Required, indicates .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items .may allow an environment where microorganisms can begin to grow. https://www.fda.gov/media/110822/download g. During a concurrent observation and interview with the [NAME] 1 on 6/8/2021 at 8:15 am, there was an opened bottle of water on the counter by the steam table. [NAME] 1 stated she did not know which staff this belonged to, but staff should not be keeping personal item on the food preparation counter. During a concurrent observation and interview with the DM on 6/8/2021 at 8:43 am, there was a key hanging on the food preparation counter shelf. DM stated that was staff's keys and it should not be there. DM stated personal belonging should be placed inside of their designated locker. A review of facility's policy and procedure titled Employee orientation checklist, dated 2018, indicated staff should be verified for competence on General habit . Personal items stored in employee area, not kitchen. h. During a concurrent observation and interview with DS on 6/8/2021 at 9:03 am, there was not a thermometer inside the reach-in freezer. DS stated it might have dropped during restock. A review of the temperature log posted by the freezer titled Temperature log, dated June 2021, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 44 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many showed temperature were logged only on 6/1, 6/7 and 6/8 morning shift. There was no documentation of temperature records from 6/2-6/6 morning and 6/1 to 6/8 afternoon shift. A review facility's policy and procedure titled Food receiving and storage of cold foods, dated year 2018, indicated 4. Each refrigerator must have a thermometer that is easily visible . and 5. Temperatures will be logged twice daily on all refrigerators and freezers by assigned foodservice employee. i. During a concurrent observation and interview with the Administrator on 6/8/2021 at 9:28 am, the Administrator opened the ice machine upper compartment cover for inspection. There were black residues build up along the plastic cover around the water curtain and water distribution tube (area where water runs to form ice). The Administrator stated maintenance supervisor (MS) cleaned the machine monthly and last cleaning should be done in May. The administrator stated the inside of the ice machine upper compartment was dirty and not safe for consumption and he would purchase ice instead of using ice from the ice machine. During an interview with MS on 6/9/2021 at 8:17 am, MS stated he cleaned the ice machine lower bin monthly, but he did not clean upper compartment every month, it was last done about four months ago. MS could not find manufacturer's cleaning instruction and stated he followed the cleaning instruction policy. A review of the cleaning log provided by the MS indicated last cleaning was done on 5/1/2021. A review of facility's undated policy and procedure titled Procedure for cleaning ice machine, indicated the cleaning frequency would be monthly and to Follow manufacturer's instructions. j. During an observation on 6/8/2021 at 10:09 am, there was large amount of ice buildup inside the walk-in freezer ceiling, wall, condenser, and on the food box. There were four icicles hanging down the condenser pipes and one large chunk of ice build up on another pipe. A layer of ice and frost were building up on the ceiling and wall behind the condenser. One chunk of ice was building up on a box of cheese. During an interview with the diet aide 2 (DA 2) on 6/8/2021 at 10:12 am, DA 2 stated he tried to clean the ice buildup every Tuesday and Friday when he put away deliveries. DA 2 stated ice started building up for about one month, but he never reported to anyone about it. During an interview with the DS on 6/8/2021 at 10:13 am, DS stated they never reported the ice build up to maintenance to check for repair or maintenance, DS stated kitchen staff just cleaned the ice off if there's build up in the freezer. k. During a concurrent observation and interviews with the DM on 6/8/2021 at 10:02 am, there was a bin of ground beef and a bin of cooked pasta dated 6/7/2021 in the walk-in refrigerator. DM stated ground meats beef should not be kept as leftover food and should be discarded. During a concurrent observation and interview with the DM on 6/8/2021 at 10:07 am, there was a container of egg salad dated 6/5/21. DM stated it was made on 6/5/2021 but it should be discarded because they should only keep it for a day. During an interview with the DM on 6/8/2021 at 10:21 regarding cooling log for the leftover foods and egg salad found in the walk-in refrigerator. DM stated they did not implement cool down (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 45 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many monitoring as they try to cook roasts and meat on the same day and minimize leftovers. However, DM stated if leftover were saved, they should be monitored for safe cooling. During an observation on 6/9/2021 at 9:25 a.m., there was a bin of diced chicken dated 6/8/21, one pan of pork dated 6/8/2021 inside the walk-in refrigerator. There was no cooling log implemented for the leftover chicken and pork. During an interview with the DM on 6/9/2021 at 9:30 a.m., DM stated she had not in-serviced or implement the cooling log monitoring system for the leftover foods yet. A review of facility's undated policy and procedure titled Policy for safe cooling process, indicated Food will be cooled in a safe manner that avoids the risk of foodborne illness. The procedure indicated 1. Any food item cooked or prepared hot and placed in the refrigerator or freezer to cool will be monitored .41 degrees F (Fahrenheit- unit of measurement) or below within 6 hours. l. During a concurrent observation and interview with the DM on 6/8/2021 at 10:03 am, there was one bag of raw salmon stored the shelf above a container of leftover cooked pasta and next to ready to eat foods in the walk-in refrigerator. DM stated salmon should not be stored there. A review facility's policy and procedure titled Food receiving and storage of cold foods, dated year 2018, indicated 13. Cooked foods will be stored on shelves above raw food to prevention contamination from drippings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 46 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. Residents Affected - Some Two of two garbage dumpsters were overfilled, uncovered, and cardboard boxes were scatter on the floor. This deficient practice had the potential for harborage and feeding of pests. Findings: During an observation on 6/9/2021 at 7:34 am, two garbage dumpsters outside in the parking lot were both overfilled. One dumpster lid was opened and another one was unable to close tightly due to overfilling trash. There were five empty cardboard boxes scattered outside of the kitchen door by the parking lot. During an interview with the Maintenance Supervisor (MS) on 6/9/2021 at 8:24 am, MS stated it would be everyone's responsibility to keep dumpster lids closed, and stated the facility did not have a designated staff to routinely inspect the cleanliness and environment of the dumpster area. MS stated whoever took out the trash should close the lids after trash disposal. MS stated the cardboard boxes were trash after the kitchen staff put away deliveries and could not be stored in the dumpster as both dumpsters were already full. A review of facility's undated policy and procedure titled Outdoor dumpster maintenance, indicated Dumpsters stored outside the establishment shall be easily cleanable, shall be provided with tight-fitting lids, doors or covers and shall be kept covered when not in actual use. Reference According to the 2017 U.S. Food and Drug Administration Food Code, proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. In addition, storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. All containers must be maintained in good repair and cleaned as necessary in order to store garbage under sanitary conditions as well as to prevent the breeding of flies. https://www.fda.gov/media/110822/download (p. 172). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 47 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. b. During an interview and a record review of the facility's MRR, on 6/10/2021 at 4:30 pm, the facility's Case Manager (CM) stated the facility did not have documented evidence the MRR was done for the month of May 2021. CM stated not being aware of the reason the consultant pharmacist did not do the MRR for May 2021. During an interview on 6/11/2021 at 11:42 am, the DON stated the pharmacy consultant got access to the facility's computer software on 6/8/2021. The DON stated the pharmacist consultant did not have access to the facility's computer software during the month of May 2021 due to troubles with security permissions. The DON stated the pharmacist could have done the MRR through paper, however, the resident's medications were not reviewed for the month of May 2021. During an interview on 6/11/2021 at 11:45 am, the facility's Assistant Administrator (AADM) stated the facility had problems with the security permission for outside staff (including the pharmacy consultant staff), the AADM stated the facility could have done it on paper but the option was not provided. A review of the facility's undated Quality Assurance (QA) Process policy indicated the Quality Assessment & Assurance Committee (QA&A) reported to the executive leadership and Governing Body and its responsibilities included, identifying and prioritizing problems based on performance indicator data and developing and implementing appropriate plans of action to correct identified quality deficiencies. Based on interview and record review the facility failed to: a. Ensure the quality assessment and assurance committee (the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards), reported to the facility's governing body (refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility), at least quarterly as indicated in the facility's policy and procedure. This deficient practice had the potential for the facility not to identify quality deficiencies and appropriate plans of action that could affect the residents' wellbeing. b. Develop and implement an appropriate plan of action to correct identified quality deficiencies regarding the medication regimen review (MRR, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). The MRR was not done for 24/24 sampled residents for the month of May 2021. This deficiency had the potential to result in possible use of unnecessary medications for these residents, excessive doses, and adverse drug reactions to the medication, complications and decline in the resident's status. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 48 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm a. During an interview on 6/11/2021 at 12:12 pm, with the Director of Nursing (DON), she stated the facility did not have a formal Quality Assurance and Performance Improvement QAPI meeting from January 2021 to June 2021. DON a stated she did a one on one meeting with the Medical Director (MD) on May 2021 and not with the whole committee. DON stated they did not have a formal QAPI meeting with the committee and they did not have any documents to provide they did the quarterly meeting with the QAPI committee. Residents Affected - Some During an interview on 6/11/2021 at 12:27 pm, with the Administrator (ADM), he stated they were unable to provide documentation that QAPI committee met at least quarterly from January 2021 to June 2021. ADM stated it was important to meet with the QAPI committee to be able to analyze any problems. During an interview on 6/11/21 at 12:49 pm, the DON stated it was important to meet with the QAPI committee to know the overall facility standing and to assess the plan and if any intervention was being done. A review of the undated facility's Policy and Procedure (P&P) titled, Governance and Leadership, indicated the Quality Assessment and Assurance (QA&A) committee consists of Medical Director, Administrator, Director of Nursing Services, Infection Prevention and Control Officer, Case Manager, Medical Records Designee, Assistant Administrator, Social Services Director and Activities Director. P&P indicated QA and A Committee reports to the executive leadership and Governing Body and was responsible for meeting, at minimum, on a quarterly basis or more frequently, if necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 49 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm c. A review of Resident 33's Face Sheet (admission Record), indicated the facility admitted Resident 33 on 9/26/2020 with diagnoses of chronic obstructive disease (COPD, a long-term exposure to irritants that damage the lungs and airways), respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). Residents Affected - Some A review of Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/5/21 indicated the resident was severely impaired for cognitive skills for daily decision making. The MDS indicated Resident 33 required total dependence from staff for bed mobility, transfer, and walk in room and toilet use. During an observation and interview on 6/8/2021 at 10:47 am, inside Resident 33's room, Case Manager (CM 1) stated Resident 33's oxygen tubing was touching the floor. CM 1 stated, oxygen tubing should not be touching the floor because the floor was dirty. CM 1 stated the oxygen tubing should not be touching the floor because resident might get an infection. During an interview on 6/9/2021 at 3:13 pm and concurrent record review of the facility's policy and procedure titled, IP Infection Control Guidelines for all Nursing Procedures, the Director of Staff and Development (DSD) stated the policy indicated to refer to procedures for any specific infection control precautions that may be warranted also referred to oxygen tubing should be not touching the floor because it might spread respiratory infection to Resident 33. b. During observation and upon entrance of the facility on 6/9/2021 at 7:30 am, Screener 1 checked the temperature of four surveyors (DPH 1, DPH 2, DPH 3 and DPH 4). Screener 1 did not ask for the COVID19 screening questions indicated in the facility's Visitor Screening Log: experiencing signs and symptoms of COVID- 19, history of close contact with any person with COVID- 19 and history of international travel for the past 14 days. During an interview with the facility's Infection Preventionist Nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), on 6/9/2021 at 3:30 pm and review of the facility's undated Visitor Screening Process Policy, the IP nurse stated the policy indicated the facility actively screened all visitors for fever and symptoms of COVID- 19 with results logged into a screening binder. The IP nurses stated the policy indicated visitors would answer a series of symptoms related questions asked and logged in the screening log by assigned screener. IP stated the screener must ask the visitor if they had signs and symptoms of COVID- 19 by reading each question indicated in their Visitor Screening Log. During interview with Screener 1 on 6/9/2021 at 4:05 pm and review of the facility's Visitor Screening Log dated 6/9/2021, the Visitor Screening Log indicated No, answers to the COVID- 19 screening questions for DPH 1, DPH 2, DPH 3 and DPH 4. Screener 1 was asked if she screened and asked DPH 1, DPH 2, DPH 3 and DPH 4 the questions indicated in the Visitor Screening Log on 6/9/2021 from 7:30 am to 7:40 am, Screener 1 stated, No, I forgot. Screener 1 stated she assumed the DPH surveyors did not have the COVID- 19 symptoms, so she answered No, for to the COVID- 19 screening questions. During an observation at the facility's entrance and interview with Screener 2 on 6/11/2021 at 7:30 am, Screener 1 checked DPH 5's temperature but did not asked the COVID- 19 screening questions indicated in the Visitor Screening Log. Screener 1 stated she did not ask DPH 5 of the COVID- 19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 50 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm screening questions included in the Visitor Screening Log. Screener 1stated she forgot to ask and thought the answers were No, since surveyors have been in the facility from the previous days. During an interview with DPH 5 on 6/11/2021, DPH 5 stated he was not asked about the COVID- 19 screening questions before being allowed to enter the facility. Residents Affected - Some During interview with Director of Staff Development (DSD) on 6/11/2021 at 1:25 pm and record review of the facility's Coronavirus Disease 2019 (COVID- 19) Mitigation Plan (MP, plan to reduce the risk of spreading COVID- 19 in the facility) updated 6/9/2021, indicated visitors who entered the facility were screened for fever and symptoms of COVID- 19. DSD stated the screeners were supposed to screen the visitors who entered the facility. d. During an observation on 6/8/2021 at 12:41 pm, the coffee cart in the hallway had one meal tray at the bottom shelf. There was also several tray dome lids and coffee mugs on the middle and bottom shelf. Certified Nursing Assistant 1 (CNA 1) poured coffee from the coffee cart but did not cover the coffee with a lid. During an interview with CNA 1 on 6/8/2021 at 12:42 pm, CNA 1 stated CNAs usually keep lids from the residents' room on the coffee cart. CNA 1 checked the meal tray at the bottom shelf and stated it was a tray that had already been eaten. CNA 1 also stated they poured coffee from the coffee cart but did not cover the coffee mug since there were no lids on the coffee cart. CNA 1 stated they never covered coffee when delivering coffee to the residents' rooms. During an interview with the Registered Nurse supervisor (RN 1) on 6/8/2021 at 12:49 pm, RN 1 stated anything brought out from the residents' room should not be placed on the clean cart. RN 1 stated lids and cups from the residents' room and eaten food trays should be stored on a separate cart. RN 1 stated coffee poured in the hallway should be covered when CNAs walked through the hallway to delivery meal trays. Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices, by failing to: a. Ensure Restorative Nursing Assistant 1 (RNA 1) donned (put on) protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness), when he (RNA 1), repositioned Resident 462 in bed in the facility's yellow zone (area where patients under investigation are allocated). b. Screen five visitors from the Department of Public Health (DPH) for signs and symptoms of Corona Virus Disease 2019 (COVID - 19, a respiratory illness that can spread from person to person). c. Ensure Resident 33's oxygen plastic tubing did not touch the floor. d. Ensure to follow safe/clean handling of the resident's liquid beverages. These deficient practices had the potential to spread infections, including but not limited to COVID-19 to residents, staff, and visitors. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 51 of 52 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 056117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rowland 330 W. Rowland Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. During an observation on 6/9/2021, at 4:25 pm, RNA 1 entered Resident 462's room in the yellow zone and did not wear a N95 respirator or a face shield. RNA 1 assisted Licensed Vocational Nurse 8 (LVN 8) repositioned Resident 462 in bed for wound treatment. During an interview on 6/9/2021, at 4:25 pm, RNA 1 stated he forgot to put on a face shield and N95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), when he worked in the yellow zone. During the concurrent interview on 6/9/2021, at 4:25 pm, LVN 8 stated staff should don a N95 and a face shield (a protective covering for all or part of the face), when inside the yellow zone rooms, to prevent the possible spread of covid-19 to the facility. During a review of Resident 462's Order Summary Report, dated 6/9/21, the Order Summary Report indicated Resident 462 was placed on isolation precautions for admission observation for possible exposure to COVID-19. During a review of the undated facility's Resident Cohorting System, indicated N95 respirators and eye protection were to be worn by the staff while in the yellow zone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 52 of 52

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Citations

26 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584GeneralS&S Dpotential for harm
F584 - Safe Environment
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.
0606GeneralS&S Dpotential for harm
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0711GeneralS&S Dpotential for harm
F711 - Physician Visits
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0801GeneralS&S Dpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0802GeneralS&S Fpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0808GeneralS&S Dpotential for harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Epotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0867GeneralS&S Epotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.

FAQ · About this visit

Common questions about this visit

What happened during the June 11, 2021 survey of THE ROWLAND?

This was a inspection survey of THE ROWLAND on June 11, 2021. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE ROWLAND on June 11, 2021?

Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 11, 2021