Health inspection·February 16, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure, titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised November 2011, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Change the oxygen cannulae and tubing every (7) days, or as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 2 of 4 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 555832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clara Baldwin Stocker Home for Women 527 S Valinda Avenue West Covina, CA 91790 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 0697 Provide safe, appropriate pain management 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** Based on observations, interviews, and record review the facility failed to ensure proper pain management interventions were in place for one of one sampled resident (Resident 3). Resident 3 had penile fungal dermatitis (inflammation of the skin) and the facility put on an adult brief (diaper) on Resident 3 despite Resident 3 having diagnoses of unuria (lack of urine) and oliguria (low urine output) and being continent (ability to control bowel movement) of bowel. Residents Affected - Few This failure resulted in Resident 3 to experience pain and had the potential to result in psychosocial and physical declines to Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy), end stage renal disease (kidneys cease functioning on a permanent basis), and anuria and oliguria. During a review of the GACH 1 (general acute care hospital) Summary, dated 2/13/24, the summary indicated Resident 3's active medications included Acetaminophen 650 milligrams (mg, unit of measurement), every six hours by mouth (PO), as needed (PRN), for pain. During a review of Resident 3's Progress Notes, dated 2/13/24 timed at 7:42 p.m., the note indicated Resident 3 was continent of bowel and was anuric due to kidney problems. During a review of the Order Summary Report (OSR), active order as of 2/16/24, included a physician's order dated 2/13/24, the order indicated to monitor pain level every shift and as needed and administer pain medications as ordered. The OSR include another physician's order, dated 2/14/24, the order indicated to give Acetaminophen tablet 325 mg. two tablets by mouth (PO), every six hours as needed for mild to moderate to severe pain 1-10/10 (scale of pain 1 to 10). During a review of Resident 3's History & Physical (H&P), dated 2/14/24, indicated Resident 3 had decision making capabilities. During a review of Resident 3's Skin Impairment Integrity Care Plan related to poor hygiene, initiated 2/14/24, the Care Plan indicated penile fungal dermatitis and the interventions included treatment as ordered, if ineffective notify the physician. During an interview, on 2/16/24, at 2:30 p.m., with the Licensed Vocational Nurse (LVN 2), LVN 2 stated LVN 2 would educate Certified Nursing Assistants and make them aware not to put on a diaper on Resident 3. During a concurrent observation and interview, on 2/15/24, at 2:39 p.m., with Resident 3, Resident 3 was lying in bed, wearing a diaper, and stated Resident 3 had dry skin on the top of Resident 3's penis, and it hurt. Resident 3 stated Resident 3's pain level was an 8 on a pain scale of 0 to10 (10 being the worst pain felt). Resident 3 stated staff (unknown) insisted in Resident 3 wearing a diaper and Resident 3 didn't want to or need to wear a diaper because he did not urinate. Resident 3 stated Resident 3 was able to transfer to the bedside commode. Resident 3 stated wearing a diaper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 3 of 4 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 555832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clara Baldwin Stocker Home for Women 527 S Valinda Avenue West Covina, CA 91790 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caused Resident 3 pain and the diaper hurt Resident 3's penis. Resident 3 stated Resident 3 told staff but, Resident 3 did not know staff names. During an interview on 2/16/24, at 3:52 p.m., with LVN 3, LVN 3 stated Resident 3's current pain level was a 2 out of 10. LVN 3 stated LVN 3 would call the physician regarding Resident 3 not wearing a diaper and LVN 3 would put a note [in Resident 3's medical record] not to wear a diaper after speaking with the physician. LVN 3 stated Resident 3 was bowel continent. LVN 3 stated Resident 3 wearing a diaper could cause pain and skin breakdown in the irritated penis area. During a review of Resident 3's Medication Administration Record (MAR), dated 2/1/24 to 2/29/24, the MAR indicated Resident 3 was administered 2 tablets of 325 mg Acetaminophen for pain 4 out of 10 on 2/16/24. The MAR did not indicate if the medication (Acetaminophen) was effective. The MAR indicated Resident 3 did not receive pain medication on 2/13/24, 2/14/24, and 2/15/24. The MAR indicated Resident 3 had no pain on 2/16/24. During a review of the facility's P&P, titled, Pain Assessment & Management, revised date March 2020, indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain management is a multidisciplinary care process that includes the following: a. assessing the potential for pain, b. Recognizing presence of pain, d. addressing the underlying causes of pain, g. monitoring the effectiveness of pain interventions, and h. modifying approaches as necessary. Report the following information to physician or practitioner: prolonged, unrelieved pain despite care plan interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 4 of 4