Inspection·January 12, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the CMN 1 reviewed Resident 14's MDS quarterly assessment record and stated the ARD date was October 25, 2023, but it was completed on December 16, 2023, which was 52 days past the ARD. 3. During a review of Resident 8's clinical record, the Face Sheet and the History and Physical indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included of alobar holoprosencephaly (birth defect that cause the brain not properly separate into right and left halves), congenital hydrocephalus (congenital anomalies of the central nervous system), and panhypopituitarism (the production and secretion of all hormones by the pituitary gland is reduced). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:20 AM, the CMN 1 reviewed Resident 8's MDS quarterly assessment record and stated the ARD date was November 1, 2023, but it was completed on January 11, 2024, which was 71 days past the ARD. 4. During a review of Resident 21's clinical record, the Face Sheet and the History and Physical indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included prematurity, genetic gap abnormality (disorder caused by gene mutation), severe intellectual disability (Major delays in development), and seizure disorder (happen as a result of abnormal electrical brain activity). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:30 AM, the CMN 1 reviewed Resident 21's MDS quarterly assessment record and stated the ARD was November 5, 2023, but it was completed on December 26, 2023, which was 51 days past the ARD. A review of the facility policy and procedure titled, Minimum Data Set (MDS) Assessments, dated October 20, 2021, indicated, . Quarterly Assessment (stated mandated subset or MPAF) must be completed every 92 days by the MDS coordinator or designee . A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023, page 2-35, indicated The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident ' s status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 2 of 11 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 01/12/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool) assessment was submitted and completed to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for four of four residents reviewed for resident assessment (Residents 8, 14, 21, and 41). Residents Affected - Some These failures resulted in inadequate monitoring of Residents 8, 14, 21, and 41's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. During an interview, with the Case Management Nurse (CMN 1), on January 12, 2024, at 8:48 AM, the CMN 1 stated the MDS assessments were to be submitted and completed to CMS within 14 days of the Assessment Reference Date (ARD- time frame in which the assessment was to be completed). During a review of Resident 41's clinical record, the Face Sheet (contains demographic and medical information) and the History and Physical indicated Resident 41 was admitted to the facility on [DATE], with diagnoses which included bronchopulmonary dysplasia (lungs and the airways are damaged, causing tissue destruction in the tiny air sacs of the lung), short gut syndrome ( body cannot absorb enough nutrients from food because part of the small intestine in missing or damaged), and prematurity (babies born alive before 37 weeks of pregnancy are completed) of infant. During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:39 AM, the CMN 1 reviewed Resident 41's quarterly and annual assessment and stated Resident 41's MDS quarterly assessment for November 7, 2023, was not submitted and completed within 14 days of the ARD (48 days overdue). The CMN 1 further stated Resident 41's MDS annual assessment for August 7, 2023, was not submitted and completed within 14 days of the ARD (25 days overdue). 2. During a review of Resident 14's clinical record, the Face Sheet and the History and Physical indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included hypoxic ischemic encephalopathy (a type of brain damage caused by a lack of oxygen to the brain before or shortly after birth), dyskinetic cerebral palsy (trouble controlling muscle movements that affect a person ability to move and maintain balance and posture) and respiratory failure with tracheostomy (a hole created in the windpipe [throat] that provides an alternative airway for breathing). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:42 AM, the CMN 1 reviewed Resident 14's quarterly and annual assessment and stated Resident 14's MDS quarterly assessment for October 25, 2023, was not submitted and completed within 14 days of the ARD (61 days overdue). The CMN 1 further stated Resident 14's MDS annual assessment for July 25, 2023, was not submitted and completed within 14 days of the ARD (10 days overdue). 3. During a review of Resident 8's clinical record, the Face Sheet and the History and Physical indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, diabetes insipidus (causes the fluids in the body to become out of balance where you pee a lot and feel thirsty a lot), tracheostomy, and spastic quadriplegia ((affects both arms and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 3 of 11 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 01/12/2024 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 0640 legs and often the torso and face) cerebral). Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:45 AM, the CMN 1 reviewed Resident 8's quarterly and annual assessment and stated Resident 8's MDS quarterly assessment for November 1, 2023, was not submitted and completed within 14 days of the ARD (58 days overdue). The CMN 1 further stated Resident 8's MDS annual assessment for May 2, 2023, was not submitted and completed within 14 days of the ARD (22 days overdue). Residents Affected - Some 4. During a review of Resident 21's clinical record, the Face Sheet and the History and Physical indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, seizures (a sudden, uncontrolled burst of electrical activity in the brain), and spastic quadriplegic palsy. During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:48 AM, the CMN 1 reviewed Resident 21's quarterly and annual assessment and stated Resident 21's MDS quarterly assessment for November 5, 2023, was not submitted and completed within 14 days of the ARD (51 days overdue). The CMN 1 further stated Resident 8's MDS annual assessment for May 9, 2023, was not submitted and completed within 14 days of the ARD (27 days overdue). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 11:04 AM, the CMN 1 stated they do not have a policy for submitting the MDS Assessment but stated the facility follows the guidelines from the Resident Assessment Instrument (RAI- helps gather definitive information on a resident's strengths and needs). The RAI manual titled, 42 CFR 483.20 .Resident Assessment, indicated .(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system . She acknowledged the RAI manual was not followed and should have been because it helps identify any issues in resident care and adjustments to interventions for the residents and identifying any concerns for MDS. During a review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, page 5-2, it indicated .For all non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after Assessment Reference Date (ARD) (A2300). Further review on page 5-3, it indicated Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 4 of 11 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 01/12/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure correct medication administration technique was followed by one of the three sampled licensed staff (Registered Nurse [RN2]) when an extra dose of a Heparin flush (solution used for maintenance of patency of intravenous [IV-within vein] line was not properly wasted prior to administration Resident 24. This failure had a potential for medication error (observed or identified preparation or administration of medications which is not in accordance with the prescriber's order; manufacturer's specifications or accepted professional standards) which may lead to harm for Resident 24. Findings: During a review of Resident 24's clinical record, the face sheet indicated Resident 24 was admitted to the facility on [DATE] with diagnoses which included central line-associated bloodstream infection (CLABSIprimary bloodstream infection that develops in a patient with a central venous line [made of a long, thin, flexible tube that enters your body through a vein; travels through one or more veins until the tip reaches the large vein that empties into your heart] in place within the 48-hour period before onset of the bloodstream infection that is not related to infection at another site), and severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). During a review of Resident 24's Physician's Order, dated September 3, 2022, it indicated Resident 24 had an order to received care for his central venous line, and to receive Heparin 10 units/ml [milliliter-unit of measure] NaCl [Sodium Chloride] 0.9% intravenous [IV] solution) 30 units, IV push, q[every] 12 hr; PRN [pro re nata/as needed]. During an observation on January 20, 2024, at 11:45 AM, at Resident 24's room, Resident 24 was lying in bed. Resident 24's central venous line was located at his right upper chest. During a concurrent observation and interview, with RN 2, on January 10, 2024, at 12:00 PM, RN 2 administered Heparin flush to Resident 24. RN 2 pushed 30 units/3ml and left the 20 units/2ml in the syringe. RN 2 did not waste the excess dose prior to administering the flush. RN 2 I usually waste it after administering the medication. During an interview with the Chief Nursing Officer (CNO), on January 11, 2024, at 1:35 PM, the CNO stated staff must waste the excess dose prior to giving the medication. The CNO further stated staff needed to be educated more regarding standard of practice and competency. When asked for a copy of facility policy regarding heparin flush and wasting medication prior to administration the CNO stated they do not have one. During an interview with the Director of Staff Education (DOE), on January 11, 2024, at 1:50 PM, the DOE stated, It was wrong, she [RN 2] should have wasted the excess medicine prior to giving the heparin flush. The DOE stated it can cause potential error and harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 5 of 11 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 01/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) were being maintained in accordance with their own policy and procedure for one of eight medication carts (room [ROOM NUMBER] medication cart). This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff in a highly vulnerable population of 49 residents. Findings: During a concurrent observation and interview, on January 11, 2024, at 5:50 AM, with a License Vocational Nurse (LVN 2), room [ROOM NUMBER]'s medication cart was inspected. LVN 2 stated Controlled Substance Inventory Count (CSIC) log is a form used by the facility to verify counting of controlled drugs at the change of every shift by oncoming and off going licensed staff. LVN 2 stated two nurses count the narcotics at the end and beginning of each shift, and both nurses must sign in the log. During a review of the CISC log, dated January 10, 2024, it indicated the following missing information and signature: 1. Clonazepam (used to prevent and control seizures) 2 MG (milligram - unit of measurements) tab (tablet): missing date, time, and signatures of day shift nurse and night shift nurse. 2. Valtoco (used to treat seizures) 15 MG nasal spray: missing time and signature of night shift nurse. 3. Valtoco 10 MG nasal spray: missing, date, time, and signatures of day shift nurse and night shift nurse. 4. Diazepam (used to treat anxiety, muscle spasms, and seizures) 2 MG tab: missing, date, time, and signatures for day shift nurse and night shift nurse. During a concurrent interview and review of CISC log on January 11, 2024, at 5:55 AM, with LVN 2, LVN 2 reviewed and confirmed the missing signatures, date, and time on the CISC log. LVN 2 stated, We [licensed staff] count but we forgot to sign. We both must sign. During a concurrent interview and record review, on January 12, 2024, at 9:42 AM, with Chief Nursing Officer (CNO) reviewed and acknowledged the facility's policy and procedure (P&P) titled, Controlled Substance Management-Nursing, dated June 25, 2009, which indicated, Accountability: At the change of each shift, both the licensed nurse leaving the shift and the nurse coming on duty must verify the count of controlled substances documented in both Controlled Substances Count sheets 3019-2 (SA) and 3019-6 (H). This is referred to as 'End-Of-Shift' or 'EOS' count in 3019-6(H). The CNO stated the two licensed staff nurses are required to count, sign the log at change of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 6 of 11 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 01/12/2024 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 ensure safe and sanitary practices were maintained in the kitchen when: Residents Affected - Few 1. One portion scoop with a light brown residue was found in the kitchen drawer, stored with other clean utensils. 2. One can opener with rust (a reddish or a brown substance that forms on iron or steel) was found on top of a metal food prep counter. These failures had the potential for bacteria to grow and cause foodborne illness (nausea, vomiting, and/or diarrhea) in a highly susceptible population of two residents who received prepared food from the kitchen. Findings: 1. During a concurrent observation and interview with [NAME] 1, on January 8, 2024, at 8:33 AM, one portion scoop, with a light brown residue inside, was found stored inside a kitchen drawer with other clean utensils. [NAME] 1 acknowledged the portion scoop was stored dirty and stated it should be stored clean because it could get the residents who receive food from the kitchen sick. During a concurrent interview and record review, on January 9, 2024, at 11:00 AM, the Dietary Supervisor (DS) and the Director of Nutrition Services (DNS) reviewed the facility's policy and procedure (P&P) titled, Infection Control- Nutritional Services, dated June 7, 2019, guideline: 4304- H, which indicated, .Equipment shall be thoroughly cleaned after each use .Food shall be served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact . All cooking and serving utensils and cutting boards shall be washed and sanitized after use . The DS and the DNS stated the expectation was for the portion scoop to be stored clean, without any residue. They further stated the facility's guideline was not followed and should have been. A review of the Federal FDA 2022 Food Code 4-601.11, indicated, (A) EQUIPMENT FOOD=CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (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 [NAME] 1, on January 8, 2023, at 8:36 AM, in the kitchen, one can opener with rust was found on top of a metal food prep counter. [NAME] 1 acknowledged the can opener should not have rust because it could get into the food when used, and can get the residents, who receive food from the kitchen, sick. During a concurrent interview and record review, on January 9, 2024, at 11:02 AM, the DS and the DNS reviewed the facility's P&P titled, Infection Control- Nutritional Services, dated June 7, 2019, guideline: 4304- H, which indicated, .Equipment shall be thoroughly cleaned after each use .Food shall be served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact . Food grinder, chopper, mixer, slicer, blender and other appliances shall be disassembled, cleaned, sanitized, dried and reassembled after each use. All cooking and serving utensils (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 7 of 11 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 01/12/2024 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and cutting boards shall be washed and sanitized after use . The DS and the DNS stated the expectation was for the can opener to be clean, with no rust on it. They further stated the facility's guideline was not followed and should have been. A review of the Federal FDA 2022 Food Code 4-601.11, indicated, (A) EQUIPMENT FOOD=CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (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. Event ID: Facility ID: 555587 If continuation sheet Page 8 of 11 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 01/12/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate and complete documentation for one of three residents (Resident 17) reviewed for hydration when there were missing intake and output documentation's (used for the purpose of documenting and tracking information regarding the fluid given and removed from the resident) from December 9, 2023 to December 21, 2023 on Resident 17's medical record This failure had the potential for Resident 17 to have unmet care needs due to incomplete and inaccurate medical information. Findings: During a review of Resident 17's clinical record, the Face Sheet (contains demographic and medical information) and the History and Physical indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a group of conditions that affect movement and posture caused by damaged that occurred to the developing brain) and tracheostomy (opening into the windpipe, from outside the neck, to help air and oxygen reach the lungs). During a record review of Resident 17's Physician's Orders, dated December 9, 2023, it indicated Resident 17 had an order to receive an intravenous (IV-into a person's vein) fluid of D5 (dextrose- sugar water injected into a vein)- 0.45 NaCL (45 percent Sodium Chloride- fluid injected into a vein to hydrate) -w/ KCL (Potassium Chloride) 20 mEq (milliequivalents per liter- Unit of measurement) / L (Liter- unit of measurement) 300 ml (milliliters- unit of measurements), IV, 27.5 ml/hr .Replaced 300 ml over 8 hours .for GI (gastrointestinal- stomach) output .Every day from 1 PM to 8 PM . During a concurrent interview and record review with the Registered Nurse (RN 1), on January 10, 2024, at 3:02 PM, the RN 1 reviewed Resident 17's Intake and Output for D5- 0.45 NaCL w/ KCL 20 mEq/ L, for the month of December 2023. The Intake and Output indicated the following missing documentations: a. December 9, 2023, a total of 37.5 ml documented (missing 262.5 ml) b. December 10, 2023, a total of 112.5 ml documented (missing 177.5 ml) c. December 11, 2023, a total of 187.5 documented (missing 112.5 ml) d. December 12, 2023, a total of 225 ml documented (missing 75 ml) e. December 13, 2023, a total of 150 m documented (missing140 ml) f. December 14, 2023, a total of 0 ml documented (missing 300 ml) g. December 15, 2023, a total of 0 ml documented (missing 300 ml) h. December 16, 2023, a total of 0 ml documented (missing 300 ml) i. December 17, 2023, a total of 112.5 ml documented (missing 177.5 ml) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 9 of 11 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 01/12/2024 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 0842 j. December 19, 2023, a total of 0 ML documented (missing 300 ml) Level of Harm - Minimal harm or potential for actual harm k. December 20, 2023, a total of 0 ML documented (missing 300 ml) l. December 21, 2023, a total of 225 ml documented (missing 75 ml). Residents Affected - Few The RN 1 acknowledged the missing documentations and stated, When an IV fluid is started and running, the expectation is to document how much IV fluid is given in the intake and output to make sure resident is getting the hydration ordered. During a concurrent interview and record review with the Chief Nursing Officer (CNO), on January 12, 2024, at 8:03 AM, the CNO reviewed the facility's policy and procedure (P&P) titled, Medical Record Content .Information Management .Record of Care, dated January 29, 2021, which indicated, It is the policy of this facility that the medical record shall contain sufficient information to identify the patient, support the diagnosis, to justify the care, treatment and services, and document the course of care and results accurately and promote continuity of care among healthcare providers . The CNO further reviewed another facility's P&P titled, Medication Management .Medication Administration, dated December 21, 2023, guidelines 3300-SA, indicated, .Right DOCUMENTATION: Document administration after giving the ordered medication .Medications orders shall be reviewed and verified by the nurse whether the dose had been administered or otherwise accounted prior to the end of the shift. The nurse shall also review each patient's medication administration record (MAR) for all current and discontinued medications orders prior to hand off . The CNO stated the policies were not followed and it should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 10 of 11 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 01/12/2024 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 maintain a sanitary and safe medication storage when staff's personal items were found inside the medication cart. Residents Affected - Few This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can jeopardize the health and safety of highly vulnerable population of 49 residents. Findings: During a concurrent observation and interview on January 11, 2024, at 5:46 AM, with a License Vocational Nurse (LVN 2), a small black and white case with white small wireless earphones and small brown portable speaker were observed inside the drawer of the medication cart in room [ROOM NUMBER]. LVN 2 stated the items could be from one of the nurses, but he was not sure. LVN 2 further stated. It should not be inside the cart. During a concurrent interview and record review with the Subacute Nurse Manager (SNM) on January 12, 2024, at 9:47 AM, the SNM reviewed the facility's policy and procedure titled Section III Medication Management (MM), dated October 22, 2020, which indicated Lockable medications carts are used to store medications in the patient medications dose system. The SNM stated the medication cart should only contain patient's medications and formulas. The CNM stated It [staff's personal items] should not be stored with medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555587 If continuation sheet Page 11 of 11