Health inspection·May 15, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical problems including acute kidney injury (AKI) superimposed on chronic (long standing) kidney disease (CKD) (decline in the kidney's abilities to perform normal function), hypertension (abnormally high BP), and congestive heart failure (CHF, inefficient pumping of blood by the heart). The H&P indicated Resident 76's oral intake was modest, and the BP was low. The H&P indicated Primary Care Physician 1 (PCP 1) ordered to discontinue the diuretic (Lasix, type of diuretic), continue the IVF, and recommended to monitor the electrolytes (chemicals in the body that help regulate bodily functions like the balance between fluids inside and outside the cells) and UO closely. The H&P indicated a nephrologist (medical doctor specializing in kidney diseases) was consulted. During a review of Resident 76's Active [physician] Orders (AO) for 5/2024, the AO indicated the following: 1. Order Date: 5/5/2024 - measure weight daily at 6 AM. 2. Order Date: 5/6/2024 - Fluid restriction every shift, 2000 ml per day - 750 ml in the AM [morning], 750 ml in the PM [after noon], and 500 ml in the NOC [night]. 3. Order Date: 5/11/2024 - Moist ground textured consistent carbohydrate (same amount of carbohydrates daily), low-sodium (chemical element found in salt) diet (less than 2,300 milligrams [mg, unit of measurement] of sodium content in salt) with thin liquids (no thickeners required). During a review of Resident 76's Nephrology Progress Note (NPN 1), dated 5/13/2024, NPN 1 indicated Resident 76 had scrotal (the bag of skin that holds and helps protect the testicles) swelling that was painful with movement, swelling on both lower extremities, and some difficulty with breathing. NPN 1 indicated the plan was to administer 1 dose of Lasix 20 mg. NPN 1 indicated Resident 76's total intake was 110 ml and total output was 2,775 ml. During a review of Resident 76's NPN 2, dated 5/14/2024, NPN 2 indicated Resident 76 had a total intake of 610 ml and total output of 4,330 ml. NPN 2 indicated Resident 76 was making a lot of urine. During a concurrent interview and record review of Resident 76's medical records on 5/14/2024 at 8:58 AM with Registered Nurse 2 (RN 2), Resident 76's physician orders, physician notes, I&O, and care plans were reviewed. RN 2 stated there was no specific care plan that addressed scrotal edema and fluid restrictions (in general). RN 2 stated the urology (branch of medicine specializing in urinary systems) consult was ordered on 5/10/2024 but not included in the care plan. RN 2 stated there was no urology consult done at this time and RN 2 would follow up. RN 2 stated it was important to individualize the care plans to remind all the nurses what to do regarding resident problems with the goals and interventions to address these problems. B. During a review of Resident 16's AR, the AR indicated the facility admitted Resident 16 on 4/17/2024 with acute (sudden) kidney failure as the reason for visit. During a review of Resident 16's H&P, dated 4/18/2024, the H&P indicated Resident 16 was alert, followed commands, and the chief complaint was generalized weakness. The H&P indicated Resident 16 had a history of chronic myeloid leukemia (rare, slowly progressing blood cancer), iron deficiency anemia (abnormally low healthy red blood cells due to low iron in the body), diabetes, and end-stage renal disease (ESRD, permanent kidney failure) on hemodialysis (HD, treatment to filter wastes and water from the blood). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 2 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 During a review of Resident 16's AO's for 5/2024, the AO indicated the following: Level of Harm - Minimal harm or potential for actual harm 1. Order Date: 4/20/2024 - Measure weight daily at 6 AM Residents Affected - Some 2. Order Date: 5/6/2024 - Consult with Dietitian due to poor oral intake; Calorie Count (monitoring and documenting resident consumption of meals for the purpose of estimating the total calories consumed) for 72 hours due to resident not eating well need to assess caloric intake. During a concurrent interview and record review on 5/14/2024 at 2:14 PM with RN 3, Resident 16's physician orders, weights, I&O, and nutrition/dietary notes, nursing notes, and care plans were reviewed. RN 3 stated there was no individualized care plan [that addressed] Resident 16's nutritional deficit to reflect the interventions implemented to address Resident 16's poor oral intake. C. During a review of Resident 74's AR, the AR indicated the facility admitted Resident 74 on 5/2/2024 with DM with ketoacidosis (DKA, life-threatening complication of DM that could lead to diabetic coma or death) as the reason for visit. During a review of Resident 74's H&P, dated 5/3/2024, the H&P indicated Resident 74 was initially admitted to General Acute Care Hospital 3 (GACH 3) with altered level of consciousness (change in the state of awareness) and uncontrolled DM with extremely, high blood sugar of more than 1,500 milligrams per deciliter (mg/dL, unit of measurement with normal fasting blood sugar level range between 70 mg/dL to 99 mg/dL). During a review of Resident 74's AOs for 5/2024, AOs indicated the following: 1. Order Date: 5/2/2024 - Blood sugar check before meals and at bedtime 2. Order Date: 5/2/2024 - Dietitian Consult due to Resident 74's poor oral intake related to severe DKA, DM, and A1C (test that reflects average blood glucose levels over the past 3 months with normal A1C level below 5.7%) of 10.2%. 3. Order Date: 5/2/2024 - Dextrose Gel 40% (treatment of severely low blood sugar) 1 each po (by mouth) daily as needed. 4. Order Date: 5/2/2024 - Dextrose 50% (type of sugar, treatment for severely low blood sugar) 50 ml IV push as directed as needed. 5. Order Date: 5/12/2024 - Insulin aspart (synthetic version of human insulin, short acting, to treat DM and/or DKA) administer according to protocol subcutaneously (beneath the skin) with meals and at bedtime. During a concurrent interview and record review on 5/14/2024 at 1:22 PM with Registered Nurse 3 (RN 3), Resident 74's physician orders and care plans were reviewed. RN 3 stated Resident 74's CPs did not indicate interventions regarding DM or DKA. RN 3 stated it was important to develop and implement a care plan to use as a guide for all staff to be aware of the resident's problems, goals, and interventions and to address the problems. D. During a review of Resident 77's AR 4, the AR 4 indicated the facility admitted Resident 77 on 4/30/2024 with Guillain Barre Syndrome (GBS, a rare autoimmune disorder wherein body's immune system (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 3 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 attacks the peripheral [situated on the edge] nerves) as the main reason for the visit. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 77's H&P, dated 4/30/2024, the H&P indicated Resident 77 was alert and oriented. The H&P indicated Resident 77 had progressive weakness the past few months and lost the ability to walk, completed 5 days of intravenous immunoglobulin therapy (IVIG, healthy antibodies given through a vein to treat GBS) on 4/29/2024, and would start steroids. The H&P indicated Resident 77 had type 2 DM. Residents Affected - Some During a review of Resident 77's AO for 5/2024, the AO indicated the following: 1. Order Date: 4/30/2024 - Glucose check before meals and at bedtime 2. Order Date: 4/30/2024 - Insulin aspart administer according to protocol subcutaneously with meals and at bedtime 3. Order Date: 5/1/2024 - Regular diet 4. Order Date: 5/10/2024 - Insulin Detemir (long-acting insulin that works slowly over 24 hours to treat DM) 10 units subcutaneously twice a day at 8 AM and 9 PM. During a concurrent interview and record review on 5/14/2024 at 1:22 PM with RN 3, Resident 77's physician orders and care plans were reviewed. RN 3 stated Resident 77's CPs did not indicate interventions that addressed DM. During an interview on 5/15/2024 at 11:44 AM, the DON stated care plans must be initiated by the admitting registered nurse (in general), individualized for resident conditions, and must be updated to reflect the specific interventions. The DON stated it was important to develop and implement an individualized care plan to guide the staff in consistently providing care to address the specific problem. During a review of the facility's policy and procedure (P&P), titled Nursing Standards #N-103, effective date 11/2023, the P&P indicated the following: 1. The nursing diagnosis/problem statement must be documented on the plan of care, reviewed and revised as necessary to reflect the current resident status, and including in the communication between caregivers upon transfer of care. 2. The nursing interventions must be implemented to promote resident's, family's significant other's participation in the health maintenance, health restoration, education, independence and self-care, and rehabilitation. 3. The resident's plan of care must be revised to include identification of new problems, reprioritization of identified problems, establishment of new interventions, and new or revised goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 4 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 Based on interviews and record review, the facility failed to accurately assess the fluid volume balance (balance between the amount of fluid entering and leaving the body) for one of one sampled resident (Resident 76), who had fluid restrictions ordered by the physician. The facility failed to accurately monitor and document Resident 76's intake and output (I&O, the amount of fluids that enter and leave the body) and the daily weight in accordance with the facility's policy and procedures (P&Ps). Residents Affected - Some These failures had the potential cause a decline in Resident 76's physical and psychosocial well-being related to excess fluid in the body (fluid overload, condition in which the liquid portion of the blood [plasma] is too high causing signs such rapid weight gain, shortness of breath, high blood pressure, and swelling/edema on the arms, legs, face, and abdomen). (Cross Reference with F656) Findings: During a review of Resident 76's Inpatient Facesheet (AR, admission record), the AR indicated the facility admitted Resident 76 on 5/5/2024 with a left comminuted intertrochanteric fracture (broken hip) as the reason for visit. During a review of Resident 76's General Acute Care Hospital 1's Discharge Summary (GACH 1's DS), dated 5/5/2024, GACH 1's DS indicated Resident 76 was alert and oriented. GACH 1's DS indicated Resident 76's low blood pressure (BP, force of blood against the walls of blood vessels) and modest urine output (UO, normal 24-hour UO ranges from 800 milliliters (ml, unit of measurement) to 1,200 ml per day) on 5/3/2024. GACH 1's DS indicated Resident 76's kidney function was noted to get worse, so the diuretic (medication that causes kidneys to make more urine) was held and gentle intravenous fluids (IVF, liquids injected into a vein) were given. GACH 1's DS indicated Resident 76 had scrotal edema (swelling of the sac-like male reproductive structure). GACH 1's DS indicated the plan to closely monitor Resident 76's UO and [fluid] volume status. During a review of Resident 76's H&P, dated 5/6/2024, the H&P indicated Resident 76 had other medical problems including acute kidney injury (AKI) superimposed on chronic (long standing) kidney disease (CKD) (decline in the kidney's abilities to perform normal function), hypertension (abnormally high BP), and congestive heart failure (CHF, inefficient pumping of blood by the heart). The H&P indicated Resident 76's oral intake was modest, and the BP was low. The H&P indicated Primary Care Physician 1 (PCP 1) ordered to discontinue the diuretic (Lasix, type of diuretic), continue the IVF, and recommended to monitor the electrolytes (chemicals in the body that help regulate bodily functions like the balance between fluids inside and outside the cells) and UO closely. The H&P indicated a nephrologist (medical doctor specializing in kidney diseases) was consulted. During a review of Resident 76's Active [physician] Orders (AO) for 5/2024, the AO indicated the following: 1. Order Date: 5/5/2024 - measure weight daily at 6 AM. 2. Order Date: 5/6/2024 - Fluid restriction every shift, 2000 ml per day - 750 ml in the AM [morning], 750 ml in the PM [after noon], and 500 ml in the NOC [night]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 5 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 Residents Affected - Some 3. Order Date: 5/11/2024 - Moist ground textured consistent carbohydrate (same amount of carbohydrates daily), low-sodium (chemical element found in salt) diet (less than 2,300 milligrams [mg, unit of measurement] of sodium content in salt) with thin liquids (no thickeners required). During a review of Resident 76's Nephrology Progress Note (NPN 1), dated 5/13/2024, NPN 1 indicated Resident 76 had scrotal (the bag of skin that holds and helps protect the testicles) swelling that was painful with movement, swelling on both lower extremities, and some difficulty with breathing. NPN 1 indicated the plan was to administer 1 dose of Lasix 20 mg. NPN 1 indicated Resident 76's total intake was 110 ml and total output was 2,775 ml. During a review of Resident 76's NPN 2, dated 5/14/2024, NPN 2 indicated Resident 76 had a total intake of 610 ml and total output of 4,330 ml. NPN 2 indicated Resident 76 was making a lot of urine. During a concurrent interview and record review of Resident 76's medical records on 5/14/2024 at 8:58 AM with Registered Nurse 2 (RN 2), Resident 76's AO and I&O were reviewed. RN 2 stated the following I&O for Resident 76 were documented: 1. 5/11/2024 AM shift - 480 ml oral intake, 1,000 ml urine output 2. 5/12/2024 AM shift - No documented oral intake, 1,300 ml urine output, 110 ml IVF amount 3. 5/12/2024 PM shift - No documented oral intake, 1,475 ml urine output ***5/12/2024 total intake = 110 ml and total output = 2,775 ml*** 4. 5/13/2024 AM shift - No oral intake, 1,230 ml urine output, 110 ml IVF amount 5. 5/13/2024 PM shift - 500 ml oral intake, 3,100 ml urine output ***5/13/2024 total intake = 610 ml and total output = 4,330 ml*** RN 2 stated there was no documented evidence of Resident 76's oral intake assessment from 5/12/2024 AM shift through 5/13/2024 AM shift. RN 2 stated she RN 2 documented 0 if Resident 76 did not have any oral intake. RN 2 stated it was important to maintain accurate documentation of Resident 76's I&O to be able to monitor Resident 76's kidney problem and adjust the fluid restriction as necessary and to monitor the swelling and note if it was improving or getting worse. During a concurrent interview and record review on 5/15/2024 at 11:44 AM with the Director of Nursing (DON), Resident 76's physician orders, daily weights, and I&Os, and the facility's P&Ps were reviewed. The DON stated there was no documented evidence Resident 76 was weighed on 5/7/2024, 5/8/2024, 5/9/2024, 5/10/2024, and 5/11/2024. The DON stated maintaining accurate I&O and daily weights was important in monitoring Resident 76's possible fluid overload. During a review of the facility's P&P 1, titled Intake and Output #1-210, revised 6/2021, P&P 1 indicated the following: 1. Residents receiving IVF or with a diagnosis of CHF and/or CKD require I&O to be done every shift or as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 6 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 2. All oral fluids including enteral feedings and ice chips, all IVF must be measured and recorded as intake and all urine, emesis, liquid stools, drainage must be measured and recorded as output. Level of Harm - Minimal harm or potential for actual harm 3. The physician must be notified of any significant variance. Residents Affected - Some 4. The I&O must be documented in the electronic medical record. During a review of the facility's P&P 2, titled Weights, effective date 1/2023, P&P 2 indicated weights must be taken per physician's order, as indicated for evaluation of fluid volume status (that is, use of diuretics), or if a resident has a history of CHF or CKD. P&P 2 indicated daily weight must be recorded on the electronic medical record. During a review of the facility's P&P 3, titled Fluid Restriction, effective date 4/2023, P&P 3 indicated all the intake must be documented on the Intake and Output Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 7 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 Based on interview and record review, the facility failed to consistently monitor a resident's weight and implement Calorie Count (monitoring and documenting resident consumption of meals for the purpose of estimating the total calories consumed) in accordance with the facility's policy and procedures (P&P) for one of one sampled resident (Resident 16). Residents Affected - Some These failures had the potential to result in unmet nutritional needs due to a delay in the necessary interventions, which could lead to a physical decline to Resident 16. (Cross Reference with F656) Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted Resident 16 on 4/17/2024 with acute (sudden) kidney failure as the reason for visit. During a review of Resident 16's H&P, dated 4/18/2024, the H&P indicated Resident 16 was alert, followed commands, and the chief complaint was generalized weakness. The H&P indicated Resident 16 had a history of chronic myeloid leukemia (rare, slowly progressing blood cancer), iron deficiency anemia (abnormally low healthy red blood cells due to low iron in the body), diabetes, and end-stage renal disease (ESRD, permanent kidney failure) on hemodialysis (HD, treatment to filter wastes and water from the blood). During a review of Resident 16's Active [physician] Orders (AO) for 5/2024, the AOs indicated the following: 1. Order Date: 4/20/2024 - Measure weight daily at 6 AM 2. Order Date: 5/6/2024 - Consult with Dietitian due to poor oral intake; Calorie Count for 72 hours due to resident not eating well need to assess caloric intake. 3. Order Date: 5/7/2024 - Calorie Count for 72 hours starting on 5/7/2024 during dinner During a concurrent interview and record review on 5/14/2024 at 2:14 PM with Registered Nurse 3 (RN 3), Resident 16's physician orders, weights, intake and output, dietitian consult notes, and nursing notes were reviewed. RN 3 stated no weights were recorded for Resident 16 on 4/18/2024, 4/19/2024, 4/20/2024, 5/6/2024, and 5/11/2024. RN 3 stated the Clinical Dietitian Consult Note, dated 5/10/2024, indicated calorie count was incomplete. During a concurrent interview and record review on 5/14/2024 at 4:30 PM with Registered Dietitian 1 (RD 1), Resident 16's physician orders, calorie count, meal intake, and dietitian consult notes were reviewed. RD 1 stated Resident 16 initially had low appetite (meal intake), so the calorie count was initiated. RD 1 stated the calorie count for 5/8/2024 dinner (10% meal intake), 5/9/2024 breakfast (50% meal intake), and 5/9/2024 lunch (50% meal intake) were not accurately recorded because the menus were not saved in the calorie count envelope (facility practice, RD 1 put an envelope in the resident's room [in general] and after the resident's meal, nursing staff placed the menu with circled food items consumed by the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 8 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 - Some RD 1 then used the information to count calories) and meal intakes were not included in the calorie count. RD 1 stated calorie counts were important because they were [used] in developing Resident 16's plan of care by identifying if Resident 16 was meeting the required caloric needs. RD 1 stated if the resident (in general) was able to eat more than 50% of the meals provided, the resident could get the calories from the diet and did not require tube feedings (liquid nutrition formula directly delivered into the digestive system). RD 1 stated monitoring the resident's weight was important in determining if the resident had any weight loss or gain and was at risk for altered nutrition (less than adequate intake or absorption of food or nutrients). During an interview on 5/15/2024 at 11:44 AM, the Director of Nursing (DON) stated Resident 16 had lost weight due to poor appetite. The DON stated RD 1 ordered a calorie count to determine if Resident 16 was eating enough and to meet Resident 16's caloric needs. The DON stated if the documentation of the meal item consumed was not accurate, the calorie count would be inaccurate. The DON stated the RD (in general) would review residents' weights, but the DON was uncertain of how often the RD checked the weights. The DON stated there was no licensed nurse designated to review the daily weights to identify any significant weight gain or loss experienced by residents. The DON stated the RD must monitor weight trends of each resident to ensure any unplanned weight loss and/or gain related to nutritional issues that must be identified and addressed promptly. During a review of the facility's P&P, titled Weights, dated 1/2023, the P&P indicated weights must be taken per physician's order, as indicated for evaluation of the fluid volume status (that is, use of diuretics), or if a resident had a history of CHF or CKD. The P&P indicated daily weights must be recorded on the electronic medical record. During a review of the facility's P&P, titled Calorie Count, dated 3/2023, the P&P indicated the following: 1. Intake analysis of calories and protein also known as calorie count must be initiated within 24 hours of receipt of a physician order or is instituted by the dietitian as part of a needs assessment, protocol, or physician-ordered consult. 2. The duration of the intake analysis must be 3 days unless specified otherwise. Changes must be documented in the electronic medical record. 3. A calorie count envelope is posted in the resident's room by the dietitian or designee. 4. Nursing must record percentages of all food and beverage intake next to the food item on the menus and place in the posted calorie count envelope. 5. The dietitian or designee instructs the resident/family/nursing to list and record intake of all additional foods not on the menu or brought from home. 6. At the end of the calorie count, the dietitian must calculate and report the result of intake and appropriate nutrition intervention or plan of care in the electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 9 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure one of two residents (Resident 175) received dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) care consistent with facility policies by failing to assess Resident 175's atrioventricular shunt (AV shunt-a surgically created connection between vein and artery that allows direct access to the bloodstream for dialysis) every shift and take daily weights. Residents Affected - Some This failure had the potential to cause a delay in care for Resident 175 and decline in overall health. Findings: During a review of Resident 175's admission Record (AR), the AR indicated Resident 175 was admitted to the facility on [DATE]. During a review of Resident 175's Family Practice Progress Note (FPPN), dated 5/11/2024, the FPPN, indicated multiple diagnoses including mild cognitive (ability to think and process information) impairment, diabetes mellitus (chronic [long standing] disease that occurs when blood sugar is too high in the bloodstream) and end stage renal disease (medical condition in which a person's kidneys permanently stop functioning) on dialysis. During a review of Nurse Note (NN) dated 5/14/2024, the NN indicated Resident 175 required one person for moderate assist with bed mobility. During a review of Resident 175's Active Orders (AO) dated as of 5/14/2024, the AO indicated measuring weight daily. During a review of Resident 175's care plan (CP) titled, TCU Dialysis- Risk for Injury, dated 5/8/2024 the CP indicated interventions that included, assess AV access, and monitoring for signs and symptoms of bleeding. During a review of Resident 175's CP titled, TCU Fluid Volume Excess, dated 5/8/2024 the CP indicated an intervention for body weight monitoring. During a concurrent interview and record review on 5/14/2024 at 4:37 PM with the DON, Bruit (abnormal sound generated by flow of blood in an artery due to localized high rate of blood flow) Description (BD), and Thrill (abnormal vibration felt on the skin) Description (TD), was reviewed. The BD, and TD, indicated that during the morning shift, there was no documentation for 5/11/2024 and on 5/13/2024 [to indicate the monitoring was done]. The DON stated if it wasn't documented then it was not done. The DON stated the AV shunt needed to be assessed every shift to check if the shunt was still functioning so the resident could maintain access and be able to get dialysis. The DON stated if the dialysis access was not maintained it could lead to a delay in care of the resident and risk further decline. During a concurrent interview and record review on 5/14/2024 at 4:58 PM with the Director of Nursing (DON), Resident 175's Weight log, date range from 5/9/2024 to 5/14/2024 was reviewed. The weight log indicated weights were recorded on 5/9/2024, 5/13/2024, and on 5/14/2024. The DON stated if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 10 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 0698 weights were not documented, it [weights] was not done. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/15/2024 at 10:37 AM with the Registered Nurse (RN), the RN stated facility policy indicated to measure weights daily for any resident receiving dialysis. The RN stated it was important to measure the resident's weight to help avoid any potential fluid overload (too much fluid in the body) which could lead to aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) or pneumonia (infection that inflames the air sacs of the lungs) and could further cause a decline in the resident's health. Residents Affected - Some During a review of the facility's P&P titled, Weights #W-100, revised 10/2019 the P&P indicated under Daily Weights, 2. Weights will be taken d. patients with history of Congestive Heart Failure (CHF, condition that develops when your heart doesn't pump enough blood for your body's needs) or Chronic Renal Failure (CRF, gradual loss of kidney function). During a review of the facility's policy and procedure (P&P) titled, Care of the Patient with Arteriovenous Access #P-116 (CPAA), revised 7/2022, the CPAA indicated, the purpose of the policy was to provide information on care of a patient with vascular (relating to blood vessels) access used for hemodialysis and under Procedure 4. AV fistula/ graft: a. evaluate patency of the vascular access every shift. The CPPA further indicated, Note: if bruit or thrill is not present, then the shunt may be clotted. Notify surgeon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 11 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 - Some 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 interview and record review, the facility failed to ensure adequate monitoring of fluoxetine (trade name Prozac, a psychotropic [any drug that affected brain activities associated with mental processes and behavior] medication used to treat depression) for one of five sampled residents (Resident 77) by failing to provide documented evidence of any assessment of medication side effects/adverse effects (undesired harmful effect resulting from a medication) after multiple instances of Prozac administration. This failure had the potential to cause a decline in Resident 77's physical and/or psychosocial well-being due to possible unidentified adverse effects. Findings: During a review of Resident 77's admission record (AR 4), AR 4 indicated the facility admitted Resident?77 on 4/30/2024, with Guillain Barre Syndrome (GBS, a rare autoimmune disorder wherein body's immune system attacked the peripheral [situated on the edge] nerves) as the main reason for the visit. During a review of Resident 77's History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 77 was alert and oriented. The H&P indicated Resident 77 had progressive weakness the past few months and lost the ability to walk, completed 5 days of intravenous immunoglobulin therapy (IVIG, healthy antibodies given through a vein to treat GBS) on 4/29/2024, and would start steroids. The H&P indicated Resident 77 had a diagnosis of anxiety disorder (persistent and excessive worry that interfered with daily activities), and the plan was for Resident 77 to continue the resident's home medications including Prozac. During a review of Resident 77's Active Physician Orders (APO) for 5/2024, the APO indicated a physician's order dated 5/8/2024 for Prozac 10 mg by mouth daily for depression manifested by verbalization of feeling sadness and crying episodes. During an interview on 5/14/2024 at 11:25 AM with Pharmacist 1 (Pharm 1), Pharm 1 stated the licensed nurses were responsible for monitoring and documenting any behavior episodes and adverse effects of the psychotropic medication administered to residents (in general). Pharm 1 stated this was important to ensure residents on psychotropic medication were receiving the optimal lowest effective dose while minimizing the adverse reactions of the psychotropic medication administered. During a concurrent interview and record review on 5/14/2024 at 1:22 PM with Registered Nurse 3 (RN 3), Resident 77's physician orders, care plans, nursing notes, and medication administration records were reviewed. RN 3 stated licensed staff had administered Prozac to Resident 77 since 5/8/2024 with no adverse effects. RN 3 stated there was no documented evidence of succeeding monitoring of possible adverse effects of Prozac for Resident 77. During an interview on 5/15/2024 at 11:44 AM with the Director of Nursing (DON), the DON stated the RN administering the psychotropic medication must also monitor and document any adverse drug effects and target behaviors to determine the drug efficacy (ability to produce the desired beneficial effect). The DON stated it was important to achieve the optimal (most likely to bring success) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 12 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 effective dose to address resident's behavior without causing adverse effects due to a high dose. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management #P115, dated 12/2013, the P&P indicated the following: Residents Affected - Some 1. Informed consent included how the facility and prescriber monitored and responded to any adverse side effects and informed the resident of side effects. 2. Nurses provided the resident and/or responsible party with the black box warning (warning for certain medications that carried serious safety risks) for each prescribed psychotherapeutic medication. 3. Nurses ensured that targeted behavior manifestations were recorded on the Medication Administration Record to facilitate behavior monitoring data collection. 4. The resident's care plan included the diagnosis and drug manifestation/s for which the psychotropic medication was employed, concurrent non-drug interventions, and adverse effects monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 13 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 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 meet food safety requirements in one of one kitchen (Kitchen 1) when: Residents Affected - Some a. There was a bag of leftover food observed in the patient nourishment refrigerator that was not dated or labeled with a 3-day expiration date and patient's name according to the facility's Policy and Procedure (P&P) titled, Food Brought into Patients from the Outside. b. There were trays of fresh eggs observed in the dairy and poultry refrigerator without labels indicating if the eggs were pasteurized (heated to destroy potential pathogens). These failures had the potential to result in residents to experience food-borne illnesses. Findings: a. During a concurrent observation and interview on 5/13/2024 at 9:58 AM with the Director of Nursing (DON), a brown paper bag contained a sandwich and was observed inside the refrigerator that was in the activity room. The brown bag was not labeled with a resident name or dated. The DON stated the refrigerator was for resident use only. The DON stated the sandwich in the brown paper bag was fast food from a local sandwich shop down the street from the facility. The DON stated resident's leftover food could be stored in the refrigerator for up to three days. The DON stated the brown bag was not labeled. The DON stated left over food needed to be labeled with a resident's name and dated to make sure the food was not given to the wrong resident. The DON stated left over food needed to be dated and discarded after three days. The DON stated if a resident was given old food, they could get sick. During a review of the facility's P&P titled, Food Brought into Patients from the Outside, revised 7/2022, indicated, if patient food was brought into the facility and needed to be stored, it could be placed in the patient nourishment refrigerator in the unit. It needed to be covered, dated, and labeled with a 3-day expiration date and a patient's name. b. During a concurrent observation and interview on 5/13/2024 at 8:21 AM with the Executive Chef (EC), one tray of fresh eggs was observed in the dairy and poultry walk-in refrigerator located Kitchen 1. The eggs were not labeled to indicate if they were pasteurized. The EC stated the eggs were used in the cafeteria grill for staff and visitors. During a concurrent observation and interview on 5/13/2024 at 12:10 PM with the Director of Food Services (DFS), seven trays of fresh eggs were observed in the dairy and poultry walk-in refrigerator located in Kitchen 1. The eggs were not labeled to indicate if they were pasteurized. During a concurrent interview and record review on 5/13/2024 at 12:15 PM with the DFS, the facility's Customer's Original Invoice .(Invoice), dated 5/13/2024 was reviewed. The Invoice indicated the fresh eggs were not pasteurized. The DFS confirmed the eggs were not pasteurized. The DFS stated the eggs were used for the cafeteria. The DFS stated the only way residents could get unpasteurized eggs was if family members ordered the eggs from the cafeteria. During a concurrent interview and record review on 5/13/2024 at 12:36 PM with the DFS, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 14 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 facility's P&P titled, Food Handling Guidelines, effective date 4/2024, indicated Fresh shell eggs that are not pasteurized are used only for hard cooked, fried, or hard poached eggs and must be cooked for immediate service to a minimum internal temperature of 145°F for 15 seconds. For all other purposes, liquid pasteurized egg products are used. The DFS stated the facility would start ordering pasteurized eggs only since the facility's vendor offered fresh eggs that were pasteurized. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 15 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the Medical Director (MD) failed to attend the quarterly Quality Assessment and Assurance (QAA) Committee meeting for three of three sampled meetings, according to the facility's Policy and Procedure (P&P) titled, Quality Assurance & Performance Improvement (QAPI) Program. Residents Affected - Some This deficient practice had the potential to negatively affect the care delivered to the residents residing at the facility. Findings: During a concurrent interview and record review on 5/15/2024 at 11:12 AM with the Director of Nursing (DON), the facility's attendance logs for the QAA Committee meetings, titled Transitional Care Unit - Virtual Meeting, dated 9/18/2023, 12/18/2023, and 3/21/2023, were reviewed. The attendance logs indicated the MD did not attend the last three QAA meetings. The DON confirmed the MD did not attend the QAA meetings on 9/18/2023, 12/18/2023, and 3/21/2023. The DON stated the MD should attend the meetings to provide oversight and input. The DON stated the MD can provide input on how to communicate with providers and provide input on QAPI and Performance Improvement Projects (PIP). During a review of the facility's TCU QAA Committee - 2024, undated, the TCU QAA Committee - 2024 indicated the MD was a member (key personnel) of the QAA committee. The TCU QAA Committee - 2024 indicated the committee would meet quarterly. During a review of the facility's P&P titled, Quality Assurance & Performance Improvement (QAPI) Program, effective date 11/2023, the P&P indicated the QAPI PIP team included the MD. The P&P indicated the QA committee would meet at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 16 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for two of six sampled residents (Residents 19 & 77), who had a peripheral intravenous (IV, into the vein) catheter, in accordance with the facility's policy and procedure (P&P) on IV Therapy Peripheral: Access and Care. Residents Affected - Some a. Resident 19's peripheral IV site was observed undated/unlabeled on 5/13/2024. b. Resident 77's peripheral IV site was observed undated/unlabeled on 5/13/2024. These failures had the potential to result in an increased spread of infection in the facility. a. During a review of Resident 19's admission record (AR 1), AR 1 indicated the facility admitted Resident 19 on 4/25/2024 with diagnoses including requiring aftercare following right knee replacement surgery and lower extremity weakness. During a review of Resident 19's Minimum Data Set 1 (MDS 1, a standardized resident assessment and care-planning tool), dated 5/1/2024, MDS 1 indicated Resident 19 did not have an impairment in cognition (ability to think, remember, and reason). MDS 1 indicated Resident 19 had multiple diagnoses including opioid dependence (condition wherein it is difficult to stop taking potent pain relievers), chronic pain, dorsalgia (chronic pain in the chest, shoulder, neck, and arm regions due to spine posture), and cervicalgia (neck pain). MDS 1 indicated Resident 1 received scheduled pain medication regimen due to almost constant pain that frequently affected sleep. During a review of Resident 19's admission physician orders (APO 1) for 5/2024, APO 1 indicated an active order for hydromorphone (Dilaudid, potent opioid to treat severe pain) 0.5 mg IV push every 4 hours as needed and ketorolac (Toradol, non-steroidal anti-inflammatory drug to treat moderate to severe pain) 15 mg IV push every 8 hours. During a concurrent observation and interview on 5/13/2024 at 11:48 AM with Registered Nurse 3 (RN?3), Resident 19's peripheral IV site was observed. RN 3 stated Resident 19's IV site was not dated and needed to be removed for infection control. RN 3 stated peripheral IV sites needed to be changed every 96 hours. b. During a review of Resident 77's admission record (AR 4), AR 4 indicated the facility admitted Resident?77 on 4/30/2024 with diagnoses including Guillain Barre Syndrome (GBS, a rare autoimmune disorder wherein body's immune system attacks the peripheral nerves) and weakness. During a review of Resident 77's H&P 2, dated 4/30/2024, H&P 2 indicated Resident 77 was alert and oriented. H&P 2 indicated Resident 77 had progressive weakness the past few months and lost the ability to walk, completed 5 days of intravenous immunoglobulin therapy (IVIG, healthy antibodies given through a vein to treat GBS) on 4/29/2024, and steroids would be started. H&P?2 indicated Resident 77 had type 2 diabetes mellitus (DM, metabolic disease involving inappropriately high blood sugar levels). During a review of Resident 77's APO 2 for 5/2024, APO 2 indicated an active order dated 5/6/2024 for Resident 77 to receive Methylprednisolone Succinate (Solu-Medrol, potent anti-inflammatory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 17 of 18 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. 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 steroid to treat GBS) 60 milligrams (mg) IV push daily. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 5/13/2024 at 10:38 AM with Resident 77, Resident 77's peripheral IV site had no label or date when it was inserted, and the tape was coming off on one side. Resident 77 stated the peripheral IV site was inserted about 2 weeks ago before Resident 77 was admitted to the facility. Residents Affected - Some During a concurrent observation and interview on 5/13/2024 at 11:57 AM with RN 1, Resident?77's peripheral IV site was observed. RN 1 stated peripheral IV sites needed to be changed every 3 days to prevent infection. RN 1 stated if the resident (in general) arrived at the facility with no labeled peripheral IV site or the IV insertion date could not be identified, the admitting nurse needed to remove the IV site and insert a new one. RN 1 stated the IV site also needed to be secured with tape to prevent accidental dislodgement. During an interview on 5/15/2024 at 11:44 AM, the Director of Nursing (DON) stated peripheral IV sites needed to be changed every 96 hours per facility policy and procedure to prevent infection due to a potential entry for germs. The DON stated the RN who inserted the IV needed to label the IV site with the date of IV insertion. During a review of the facility's P&P, titled IV Therapy Peripheral: Access and Care #I-290, dated 9/2022, the P&P indicated IV therapy must be used to provide fluid, medications, and nutrition to residents. The P&P indicated all peripheral IV sites must be changed every 96 hours unless veins are difficult to assess and maintain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555610 If continuation sheet Page 18 of 18