Inspection·January 12, 2023

F 0761 Manufacturer Expiration Date: [DATE] Level of Harm - Minimal harm or potential for actual harm During a concurrent interview on [DATE], at 10:15 A.M, with Nurse Manger (NM-1), the NM-1 stated the charge nurse and the resource nurse are responsible for checking the supplies weekly. The NM-1 acknowledged the supplies were expired and stated, They missed it. Residents Affected - Few During a review of document titled, Job Description Registered Nurse (RN), revised on [DATE], indicated, .C. Medical Equipment and Point of Care Testing: manages, operates, inspects and tests nursing equipment to ensure that it is functioning safely and efficiently prior to use and remove nonfunctioning equipment from use according to hospital policy . During a review of the facility's guideline document titled, Infection Control-Materials Management, dated [DATE], indicated, Stock Rotation All items in the material management will be checked for expiration dates at least monthly. The unit department staff will check items in the supply room in different units/departments/monthly. Care should be taken to rotate stock on hand to the front of shelf, putting the new stock to the rear so that rotation is always in effect. Use oldest items first . 2. During a concurrent medication storage observation and interview, on [DATE], at 10:32 AM, with the CRN-1, the CRN-1 acknowledged the open Evrysdi oral solution was expired on [DATE], and was stored in the locked substance control box. The CRN-1 stated, it was the responsibility of the bedside nurse and the charge nurse to check the medication expiration date. The CRN-1 further stated, the locked substance control box is only for narcotics. During a concurrent interview on [DATE], at 10:48 AM, with the NM-1, the NM-1 stated, the charge nurse and the Resource Nurse are responsible for checking the medication refrigerator weekly and expired medication should have not been in the locked substance control box. During a review of the facility's guideline document titled, Drug Procurement, Storage, Inspection, & waste, indicated, . Expired, damaged and/or contaminated medications will be removed form drug storage areas within the D/P-SNF during the Pharmacy inspection and will be returned to the Pharmacy/ Provider Pharmacy for proper disposal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 2 of 5 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 555587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Rehabilitation Hospital - D/P Snf 1720 Mountain View Loma Linda, CA 92354 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: Residents Affected - Few 1. One cooking pan stored, hung above the three-compartment sink, with grease and sticky residue on the inside and outside of the pan. 2. One baking pan had rust (a reddish or a brown substance that forms on iron or steel) at the back area of the pan. These failures had the potential for bacteria growth and cause foodborne illness (nausea, vomiting, and/or diarrhea) in a highly susceptible population of three residents who received food from the kitchen from a universe of 50 residents. Findings: 1. During a concurrent observation and interview with [NAME] 1, on January 9, 2023, at 8:10 AM, observed one cooking pan stored, hung above the three-compartment sink, with grease and sticky residue on the inside and outside of the pan. [NAME] 1 acknowledged the pan was stored with grease and was sticky on the inside and outside, and stated the pans should be stored clean without any residue. During a review of the facility's guideline document titled, Infection Control- Nutritional Services, dated June 7, 2019, guideline: 4304- H, indicated, .All cooking and serving utensils and cutting boards shall be washed and sanitized after use . During a concurrent interview and record review with the Dietary Service Supervisor (DSS), and the Director of Nutrition Registered Dietitian (DNRD), on January 11, 2023, at 9:41 AM, the DSS and the DNRD, stated their expectation of the pans were to be stored clean, without any grease or sticky residue.The DSS and the DNRD reviewed facility's guideline document titled, Infection Control- Nutritional Services, dated June 7, 2019, and both the DSS and the DNRD, stated the facility's guideline document was not followed. During a review of the Federal FDA 2017 Food Code 4-601.11, indicated, .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . 2. During a concurrent observation and interview with the DSS and the DNRD, on January 9, 2023, at 2:52 PM, there was one baking pan that was stored with rust at the back of the baking pan. The DNRD and the DSS acknowledged the baking pan had rust at the back of the pan, and stated the baking pan should not have any rust because the rust contaminate the food. During a concurrent interview and record review with the DNRD and the DSS, on January 11, 2023, at 9:41 AM, the facility's guideline document titled, Infection Control- Nutritional Services, dated June 7, 2019, guideline: 4304- H, indicated, .All cooking and serving utensils and cutting boards shall be washed and sanitized after use . The DNRD and the DSS stated the facility's guideline document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 3 of 5 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 555587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Rehabilitation Hospital - D/P Snf 1720 Mountain View Loma Linda, CA 92354 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 was not followed. Level of Harm - Minimal harm or potential for actual harm During a review of the Federal FDA 2017 Food Code 4-601.11, indicated, .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 4 of 5 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 555587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Rehabilitation Hospital - D/P Snf 1720 Mountain View Loma Linda, CA 92354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure contact (spread by touching) and droplet (spread through respiratory secretions) isolation practices were maintained to provide a sanitary environment to help prevent the possible development and transmission of Respiratory Syncytial Virus (RSV -causes infections of the lungs) infection when the curtain was not completely closed in a shared room, separating Resident 14 and the roommate who was not on isolation precautions. Residents Affected - Few This failure had the potential to result in the spread of RSV infection from Resident 14, in an isolation bed, to the other residents residing in the room. Findings: During a review of Resident 14's History and Physical Examination (H&P), dated September 15, 2021, by Physician 1, the H&P indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses that included chronic lung disease with tracheostomy (a surgical hole in the front of the neck) and ventilator dependence (relying on a machine to assist with respirations). During a review of Resident 14's clinical record titled, ORDER SHEET, dated December 12, 2022, by Physician 2, indicated, Patient Isolation .Contact and Droplet Precautions, Constant Indicator, RSV. During a concurrent observation and interview on January 9, 2023, at 3:15 PM, with the Infection Preventionist Nurse (IPN), there was a sign on the door which indicated, Isolation Precautions. Observed Resident 14's curtain to be wide open in-between Resident 14, who was identified to be on Contact and Droplet Precautions and the roommate, who was not on any isolation precautions. The IPN confirmed the curtain was not closed between Resident 14 and the roommate and stated, The curtain is supposed to be closed between the two residents. During an interview on January 9, 2023, at 3:19 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated, Resident 14 is on contact and droplet isolation precautions, but I did not know the curtain had to be closed in between the two residents. During a review of the facility's guideline document titled, Isolation Precautions, guideline 4054-H, dated April 21, 2021, indicated, . Droplet Precautions . drawing the curtain between patient beds is especially important for patients in multi-bedrooms with infections transmitted by the droplet route . During a concurrent interview and record review on January 9, 2023, at 3:22 PM, with the IPN, the facility's guideline document titled, Isolation Precautions, guideline 4054-H, dated April 21, 2021, was reviewed. The IPN stated, the facility was not followed guideline document and the curtains should have been closed between the two residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 5 of 5