Health inspection·September 5, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impairment. The MDS indicated Resident 5 required limited assistance (resident highly involved in activity, staff provide non-weight-bearing assistance) with transfers and supervision with bed mobility, locomotion (how resident moves between locations), toilet use, and the resident was independent with eating. During an observation on 9/5/2023 at 10:50 am, AD came out of a resident's (unidentified) room without performing hand hygiene and went inside Resident 4's room without hand hygiene. AD adjusted Resident 4's table, picked up an object from the floor, touched Resident 4's curtain and the closet door inside Resident 4's room. AD did not perform hand hygiene upon leaving Resident 4's room. During an observation on 9/5/2023 at 10:54 am, AD went inside Resident 5's room, AD touched and moved Resident 5's table and removed Resident 5's meal tray from the table. AD placed Resident 5's meal tray into the meal cart and without performing hand hygiene, AD entered another resident's (unidentified) room without washing her hands. During an interview on 9/5/2023 at 10:56 am, AD stated she forgot to wash her hands and stated she needed to sanitize her hands upon exiting a resident's room. A review of the facility's undated Policy and Procedure (P&P) titled Handwashing/Hand Hygiene, the P&P indicated the facility consider hand hygiene the primary means to prevent the spread of infections. The P&P indicated to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations .before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, after removing gloves . b. During a review of Resident 6's admission Record, the admission record indicated the facility admitted the resident on 9/21/2017, with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease that causes obstructed airflow from the lungs) and diabetes (high blood sugar level). During a review of Resident 6's MDS dated [DATE], the MDS indicated the resident sometimes was able to understand verbal content and sometimes able to express ideas and wants. The MDS indicated Resident 6 required moderate assistance with bed mobility, dressing, and personal hygiene and totally dependent with toilet use. During a review of Resident 7's admission Record, the admission record indicated the facility admitted the resident on 12/2/2021 with diagnoses that included COVID-19 and COPD. During a review of Resident 7's MDS dated [DATE], the MDS indicated the resident was moderately impaired for daily decision making. The MDS indicated the resident was totally dependent with transfers, dressing, and toilet use and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, eating and personal hygiene. During an observation on 9/5/2023 at 12:30 pm, Hospice Staff 1 assisted Resident 6 back to her room after a shower, using the shower chair. During an observation on 9/5/2023 at 12:33 pm, CNA 1 provided massage with lotion to Resident 7's back who complained of discomfort to the back. Hospice Staff 1 asked CNA 1 for assistance to transfer Resident 6 from the shower chair to the bed. CNA 1 went from Resident 7's bed to Resident 6's bed without removing her gloves and using the same gloves, CNA 1 assisted Hospice Staff 1 to transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 2 of 3 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 09/05/2023 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 Resident 6 back to bed. CNA 1 proceeded to straighten the bed cover under Resident 6 after the transfer, using the same gloves. During an interview with CNA 1 on 9/5/2023 at 12:36 pm, CNA 1 stated she forgot to change gloves when the Hospice Staff 1 asked for assistance to transfer Resident 6. CNA 1 stated she needed to change gloves when providing care in between residents. A review of the facility's P&P titled Standard Precautions indicated to remove gloves promptly, before touching non-contaminated surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. c. During an observation on 9/5/2023 at 12:37 pm, Hospice Staff 1 brought the shower chair from Resident 6's room after using the shower chair to provide a shower to Resident 6. Hospice Staff 1 got a paper towel and poured hand sanitizer on the paper towel to wipe the shower chair. During a concurrent interview, Hospice Staff 1 stated he could not find disinfecting wipes, so he used the paper towel soaked with hand sanitizer to clean the shower chair. During an observation on 9/5/2023 at 2:06 pm with the Administrator, there were no disinfectant wipes available close to the residents' rooms. The disinfectant wipes were found at the nurse's station and inside the locked medication carts. During a review of the facility's undated P&P titled Standard Precautions with the Administrator on 9/5/2023 at 2:10 pm, the P&P indicated to ensure reusable equipment is not used for the care of another resident until it has been appropriately cleaned. During a concurrent interview with the Administrator, using the disinfecting wipes is the appropriate cleaning material for the shower chair. During a review of the United States EPA guideline, the guideline indicated a review of the disinfectant list indicated hand sanitizers was not on the list of disinfectants for hard nonporous surfaces. A review of the Center for Disease Control and Preventions (CDC) guidelines for disinfection and sterilization in healthcare facilities dated 2008, the guideline indicated noncritical surfaces (e.g., dialysis bed or chair, countertops, external surfaces of dialysis machines, and equipment [scissors, hemostats, clamps, blood pressure cuffs, stethoscopes]) should be disinfected with an EPA-registered disinfectant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056117 If continuation sheet Page 3 of 3