Health inspection·November 27, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/25/2024 at 1:08 PM, with Certified Nurse Assistant (CNA) 2, CNA 2 stated that call lights ensure resident safety and should be always within reach. CNA 2 stated call lights allowed residents to communicate their needs. CNA 2 stated that the call lights for Residents 21 and 25 weren't within reach and should have been easily accessible in case the residents (Residents 21 and 25) needed help. Residents Affected - Some During an interview on 11/27/2024 at 11:17 AM, with the Director of Nursing (DON), the DON stated that call lights are a critical communication tool for residents to quickly request assistance when needed, which is vital for their safety and well-being, preventing potential falls or complications by allowing them to summon help immediately in case of discomfort, pain, or an emergency. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revision dated 3/2021, the P&P indicated that the purpose of this procedure is to ensure timely responses to the resident's requests and needs and when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 2 of 23 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 11/27/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CROSS REFERENCE - F656 and F676 Residents Affected - Few Based on interview and record review, the facility failed to develop a comprehensive communication assessment for Resident 2 who primarily spoke Arabic, as indicated in the facility's policy and procedure. This deficient practice had the potential to result in Resident 2 being unable to communicate the residents needs and wants and not receive individualized care to meet the resident's medical, nursing, and mental and psychosocial needs that would have been identified in the language assessment. Findings: During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of the Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/23/2024, the MDS indicated Resident 2 needed or wanted an interpreter to communicate with a doctor or health care staff due to Arabic was the resident's preferred language. The MDS indicated Resident 2 sometimes understood (limited concrete request) and sometimes understood others (respond to simple direct communication). Resident 2 was dependent (helper does all the effort) with showering, toilet hygiene, dressing, and sit to lying position. During an observation and concurrent interview with Resident 2 with Certified Nurse Assistant 5 (CNA 5), while at the resident's bedside, on 11/25/2024 at 11:08 am, Resident 2 was attempting to communicate with CNA 5. CNA 5 stated Resident 2 did not speak English and continued to attempt to communicate with the resident without using any form of communication tool. CNA 5 stated CNA 5 communicated with Resident 2 by facial grimacing, pointing at items and the resident nodding her head. During an interview and concurrent observation inside Resident 2's room, on 11/26/2024 at 12:14pm, with Licensed Vocational Nurse 4 (LVN 4) Resident 2 was observed in bed eating lunch. Resident 2 was observed attempting to communicate with LVN 4, speaking in Arabic while pointing at his food. LVN 4 attempted to communicate with Resident 2 in English. However, LVN 4 stated Resident 2 only spoke Arabic and did not use any tool to communication with Resident 2. LVN4 stated it was important to provide a form of communication with Resident 2 so the resident can tell us (staff) his needs and wants. During an interview and record review of Resident 2's paper and electronic chart, on 11/26/2024 at 1:15 pm, a Registered Nurse (IPN) stated communication was important to inform the staff of basic needs, such as water. IPN stated Resident 2 was not assessed regarding the resident ability and preferred way of communication. IPN stated Resident 2 only spoke and communicated in Arabic and there should have been a communication assessment done upon admission addressing his preferred language to communicate, so we (staff) can really know what is going on with the resident and provide the proper care the resident needs. IPN stated without a communication tool, the staff is just guessing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 3 of 23 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 11/27/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy titled admission Assessment and Follow Up: Role of the Nurse, indicted the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments . Conduct a physical assessment, including the following systems: Eyes, Ears, Nose and Throat. Residents Affected - Few During a review of the facility's policy titled Translation and/or Interpretation of Facility Services, dated 11/2020, indicated the facility's language access program will ensure that individuals with limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. When encountering LEP individuals, staff members will conduct the initial language assessment (e.g., I speak cards) and notify the staff person in charge of the language access program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 4 of 23 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 11/27/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop or implement an individualized person-centered care plan for one of one sampled resident (Resident 2) who only spoke and understood Arabic (language of the Arabs) as indicated in the facility's policy. This failure had the potential to result in unmet individual needs and not receiving the necessary care and services for Resident 2 to achieve an optimal level of function and had the potential to affect the resident's physical well-being. CROSS REFERENCE - F636 and F676 Findings: During a review of the admission Record of Resident 2, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of the Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/23/2024, indicated Resident 2 needed or wanted an interpreter to communicate with a doctor or health care staff due to Arabic was the resident's preferred language. The MDS indicated Resident 2 sometimes understood (limited concrete request) and sometimes understood others (respond to simple direct communication). Resident 2 was dependent (helper does all the effort) with showering, toilet hygiene, dressing, and sit to lying position. During an observation and concurrent interview with Resident 2 with Certified Nurse Assistant 5 (CNA 5), while at the resident's bedside, on 11/25/2024 at 11:08 am, Resident 2 was attempting to communicate with CNA 5. CNA 5 stated Resident 2 did not speak English and continued to attempt to communicate with the resident without using any form of communication tool. CNA 5 stated CNA 5 communicated with Resident 2 by facial grimacing, pointing at items and the resident nodding her head. During an interview and concurrent observation inside Resident 2's room, on 11/26/2024 at 12:14pm, with Licensed Vocational Nurse 4 (LVN 4) Resident 2 was observed in bed eating lunch. Resident 2 was observed attempting to communicate with LVN 4, speaking in Arabic while pointing at his food. LVN 4 attempted to communicate with Resident 2 in English. However, LVN 4 stated Resident 2 only spoke Arabic and did not use any tool to communicate with Resident 2. LVN 4 stated it was important to provide a form of communication with Resident 2 so the resident can tell us (staff) his needs and wants. During an interview and concurrent record review with the Registered Nurse (IPN), of Resident 2's paper and electronic charts, on 11/26/2024 at 1:13 pm, IPN stated Resident 2 did not have a care plan regarding communication. IPN stated Resident 2 should have had a communication care plan so staff will know the type of language the resident spoke and/or the type of tool used to communicate with the resident. During a review of the facility's policy titled Care Plans - Baseline, revised on 12/2016, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 5 of 23 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 11/27/2024 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 0656 baseline care plan will be used until for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 6 of 23 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 11/27/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 2) was provided a communication tool or resources to effectively communicate his needs. Resident 2 who spoke Arabic (language of the Arabs), was not provided a communication tool. Residents Affected - Few These deficient practices had the potential to result in the resident's care needs not being effectively conveyed to the staff which could lead to a decline in the resident's quality of life. Cross reference with F636 and F656 Findings: During a review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body), dysphagia (difficulty swallowing), psychosis (loss of contact with society) and hearing loss. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care-screening tool), the MDS dated [DATE], indicated Resident 2 needed or wanted an interpreter to communicate with a doctor or health care staff due to Arabic was the resident's preferred language. The MDS indicated Resident 2 sometimes understood (limited concrete request) and sometimes understood others (respond to simple direct communication). Resident 2 was also dependent (helper does all the effort) with showering, toilet hygiene, dressing, and sit to lying position. During an observation and concurrent interview with Resident 2 and Certified Nurse Assistant 5 (CNA 5), while at the resident's bedside, on 11/25/2024 at 11:08 am, Resident 2 was attempting to communicate with CNA 5. CNA 5 stated Resident 2 did not speak English and continued to attempt to communicate with the resident without using any form of communication tool. CNA 5 stated CNA 5 communicated with Resident 2 by facial grimacing, pointing at items and the resident nodding her head. During an interview and concurrent observation inside Resident 2's room, on 11/26/2024 at 12:14pm, with Licensed Vocational Nurse 4 (LVN 4) Resident 2 was observed in bed eating lunch. Resident 2 was observed attempting to communicate with LVN 4, speaking in Arabic while pointing at his food. LVN 4 attempted to communicate with Resident 2 in English. LVN 4 stated, I will call your daughter. LVN 4 did not use any tool to communication with Resident 2. LVN 4 stated it was important to provide a form of communication with Resident 2 so the resident can tell us (staff) his needs and wants. During an interview with a Registered Nurse (IPN), on 11/24/2024 at 1:15 pm, IPN stated communication was important to determine what the resident needs; if the resident was in pain or needed water. During a review of the facility's policy, Translation and/or Interpretation of Facility Services, revised on 11/2020, the policy indicated the facility 's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Family members and friends shall not be relied upon to provide interpretation services for the resident . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 7 of 23 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 11/27/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy titled Interpreter Policy and Procedure, the policy indicated the Facility will assist in providing interpreter services to the resident. Upon admission, staff will identify residents in need of interpreter services; use communication board. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 8 of 23 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 11/27/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some C. During a review of Resident 38's AR, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnosis that included respiratory failure (a serious condition that happens when your lungs cannot get enough oxygen into your blood), acute congestive heart failure (CHF, heart doesn't pump enough blood for your body's needs), hemiplegia and hemiparesis (cause weakness or paralysis on one side of the body) and diabetes (uncontrolled blood sugar levels in the blood). During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 had severe cognitive impairment, and was dependent with oral and toilet hygiene, roll from left to right, and chair/bed/toilet transfers. During a review of Resident 38's physicians orders, dated 10/4/2024, indicated for a STAT chest x-ray due to cough was ordered for the resident. During a review of Resident 38's Medication Administration Record (MAR), indicated a STAT chest x-ray was ordered on 10/4/2024 at 12:15 pm, by the resident's physician. During an interview and concurrent record review with the Director of Nursing (DON), on 11/26/2024 at 9:22 am, the DON stated Resident 38's STAT chest x-ray was not done. DON stated, it has been an issue with the x-ray company (diagnostic imaging [images of inside the body] company), we ask for STAT and the technician will come four to six hours later. DON stated physician orders should be followed as ordered to provide the right care for the resident. The DON stated STAT orders should be done within two hours to determine if any immediate interventions are needed and for the physician to decide or change the plan of care. During a review of the facility's undated P&P, titled Carrying Out Physician's Order, indicated to use physician order to communicate directions for ancillary services and required diagnostic (x-ray) test. During a review of the facility's P&P titled, Physician Orders, with an effective of 3/22/2022, indicated the facility will ensure that all physician orders are complete and accurate. Multiple efforts were made in attempt to obtain a policy regarding following physician's orders throughout the survey, however, the requested policy was not submitted for review. Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three sampled residents (Residents 15, 23, and 38) by failing to: A. Ensure Resident 15 had padded side rails to prevent injury from potential seizures, per physician's orders. B. Ensure and monitor that hospice staff were signing in and out during visits for Resident 23. C. Ensure Resident 38 physician's orders to obtain a STAT (right now, immediate) chest x-ray (images of inside the body) were followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 9 of 23 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 11/27/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These deficient practices resulted in the failure to the delivery of necessary care and services for Residents 12, 23 and 24. Findings A. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 6/25/2019, and re-admitted on [DATE], with diagnoses including seizures (a temporary episode of abnormal electrical activity in the brain that causes a person to experience changes in their body and behavior), hypertension (a condition where the pressure of blood in your blood vessels is consistently too high), and dementia (a group of neurological conditions that cause a decline in mental functioning, such as thinking, remembering, and reasoning). During a review of Resident 15's History and Physical (H&P), dated 12/23/2023, indicated Resident 15 did not have the capacity to understand and make decisions. A review of the Care Plan dated 3/6/2024, the Care Plan that Resident 15 used bilateral padded half side rails to prevent potential injury during seizure episodes. The Care Plan goal indicated that Resident 15 would not have injury related to side rail use. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2024, the MDS indicated Resident 15 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. A review of the Bed Rail assessment dated [DATE], the Bed Rail Assessment indicated had an alteration in safety awareness due to cognitive decline. A review of the Order Summary Report dated 11/26/2024, the Order Summary Report indicated that Resident 15 had an active order to have bilateral padded siderails to prevent potential injury/injuries during seizures episodes. During an observation on 11/26/2024 at 3:45 PM, Resident 15 had no bilateral padded side rails. During an interview on 11/26/2024 at 3:59 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that all orders should be carried out and orders that are not cut and dry (a term used to indicate clear and definite situation) should be clarified with the physician immediately. LVN 3 stated that Resident 15 did not have bilateral padded side rails to her bed for her safety. LVN 3 stated that padded side rails are used as a safety measure to prevent serious injuries in case of seizure activity and Resident 15 should have had bilateral padded side rails. During an interview on 11/27/2024 at 11:17 AM, with the Director of Nursing (DON), the DON stated that all physician orders should be carried out and should be done in a timely manner. The DON stated that carrying out physician orders ensures the patient receives the most appropriate treatment plan based on their medical needs, which can significantly improve their health outcomes by minimizing complications. The DON stated that clarifying medical orders from the doctor is important to ensure patient safety by preventing errors and minimizing potential harm. During a review of the facility's P&P titled, Safety and Supervision of Residents, revision dated 7/2017, the P&P indicated that the facility strived to make the environment as free from accident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 10 of 23 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 11/27/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. B. During a review of Resident 23's AR, the AR indicated the facility admitted Resident 23 on 5/11/2024, with diagnoses including bacteremia (a condition where bacteria are present in the bloodstream), urinary tract infection (UTI, a condition in which bacteria invade and grow in the urinary tract), and difficulty walking. A review of the Hospice and Palliative Care Staff Assignment dated 5/28/2024, the Hospice and Palliative Care Staff Assignment indicated: 1. The hospice Registered Nurse (RN) would visit Resident 23 at the facility every 14 days and as needed. 2. The hospice LVN would visit Resident 23 at the facility once a week and as needed. 3. The Certified Homemaker-Home Health Aide (CHHA) would visit Resident 23 at the facility three times a week. A review of the Hospice and Palliative Care Staff Sign-In Sheet from dated 5/28/2024 to 10/12/2024, the Staff Sign-In Sheet indicated that the hospice staff had not been signing-in according to the staff assignment frequency. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had severe cognitive (the ability to thin and process information) impairment. The MDS indicated Resident 23 was dependent with ADL and dependent with mobility. During an interview on 11/26/2024 at 10:28 AM, with the Registered Nurse (RN), the RN stated that the hospice staff had not been signing in consistently as indicated by the staff assignment sign-in sheet. The RN stated that it was important that the hospice staff document their visits in the sign-in sheet as it signifies their official involvement in the resident's care which allows them to collaborate closely with the facility staff to provide specialized end-of-life care. The RN stated that this enhanced the comfort and quality of life for the dying resident. During an interview on 11/27/2024 at 11:17 AM, with the DON, the DON stated that it was important for the facility to ensure that hospice staff always documented their presence, because it allowed for clear communication with the facility staff regarding the patient's care and ensure proper coordination of services between the hospice team and the facility staff. The DON stated that this was important especially when providing end-of-life care to a resident in the facility, because it helped maintain a comprehensive care plan and avoid potential gaps in treatment. During a review of the facility's Policy and Procedure (P&P) titled, Hospice Program, revision dated 7/2017, the P&P indicated Hospice providers who contract with the facility are held responsible for meeting the same professional standards and timelines of service as any contracted individual or agency associated with the facility. The P&P indicated The Facility ensures that facility staff provide orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 11 of 23 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 11/27/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency. Findings: During a review of Resident 191's admission Record, (AR) , the AR indicated Resident 191 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) dependence on hemodialysis and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 191's History and Physical, (H&P) dated 11/23/2024, the H&P indicated Resident 191 did not have decision making capacity. The H&P, indicated Resident 191 could independently bathe, feed, and dress self. During a review of Resident 191's Order Summary Report, (OSR) with active orders as of 11/26/2024, the OSR, indicated Resident 191 required hemodialysis every Monday, Wednesday, and Friday from 1:30 PM to 5:30 PM. During a concurrent observation and interview 11/26/2024 at 10:01 AM with Licensed Vocational Nurse (LVN) 2 in Resident 191's room, LVN 2 could not find the emergency kit in Resident's 191's bedside drawers or closet and stated Resident 191 should have the emergency kit but did not. LVN 2 stated the purpose of the emergency kit was to have it available to the residents quickly during emergencies and the dressings inside the kit would be used to stop any potential bleeding from the resident's dialysis site. During a concurrent interview and record review on 11/27/2024 at 7:00 AM with Director of Nursing (DON), the facility's policy and procedure (P&P) Hemodialysis Access Care, dated 9/2010 was reviewed. The P&P indicated under Care Immediately Following Dialysis Treatment, 4. If there is major bleeding from the site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do no leave resident alone until emergency services arrive. DON stated the passage does not specifically mention an emergency kit, but it was necessary to have one at the bedside because the resident cannot be left alone if they begin to bleed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 12 of 23 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 11/27/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide, restore, or improve normal bladder function for one of two sampled residents (Resident 92) whose urinary indwelling foley catheter (a tube that removes urine from the bladder to a collection bag) was observed with the presence of sediments (cells, debris and other solid matter in urine). This deficient practice had the potential to result in catheter related complications such as urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra). Findings: During a review of Resident 92's admission Record (AR), the admission record indicated the resident was admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease (disease causing memory loss and other mental functions), psychosis (abnormal condition of the mind that involves a loss of contact with reality), and hypertension (elevated blood pressure). During a review of Resident 92's Second 90 Day Physician Recertification of Terminal Illness, dated 11/1/2024, the recertification indicated the resident was awake and oriented to person (himself) only. During a review of Resident 92's physician's orders, the orders indicated an indwelling foley catheter was ordered for Resident 92 due to uropathy (urine flow is blocked) and to change the indwelling catheter or foley bag as needed. During an observation and concurrent interview with Licensed Vocational Nurse 5 (LVN 5), on 11/25/2024 at 12:33 pm, Resident 92 was in bed, the resident's foley catheter tubing was observed with dark amber color with sediments in the urine. LVN 5 stated sediments in the foley can harm the resident as it may indicate a form of infection. LVN 5 stated Resident 92's physician should have been informed to determine what was causing the resident's urine to be dark with sediments. During an interview with a Registered Nurse (IPN), on 11/26/2024 at 1:30 pm, the IPN stated foley catheter care was done daily. The IPN stated sediments should not be in Resident 92's urine as it was a sign of infection. During a record review of Resident 92's care plan titled Foley Cather for Uropathy,, dated 11/20/2024, the care plan indicated the resident will show no signs and symptoms of urinary infection (an infection in any part of the urinary system including the kidneys) as part of the facility's goal. The listed interventions included to monitor/record/report to the physician symptoms of pain, burning, blood tinge urine, cloudiness as part of the facility's intervention. A review of the facility's policy titled Catheter Care - Urinary, revised on 9/2014, the policy indicated the purpose of the procedure was to prevent catheter-associated urinary tract infections and indicated to observe the resident for complications associated with urinary catheters, to check the urine for unusual appearance (color, blood, etc.). Observe for other signs and symptoms of urinary tract infection . and report findings to the physician or supervisor immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 13 of 23 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 11/27/2024 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 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** Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 191) who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) had been provided with an emergency kit at the resident's bedside. This deficient practice had the potential to delay treatment to Resident 191 when needed during an emergency. Findings: During a review of Resident 191's admission Record, (AR), the AR indicated Resident 191 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) dependence on hemodialysis and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 191's History and Physical, (H&P) dated 11/23/2024, the H&P indicated Resident 191 did not have decision making capacity. The H&P, indicated Resident 191 could independently bathe, feed, and dress self. During a review of Resident 191's Order Summary Report, (OSR) with active orders as of 11/26/2024, the OSR, indicated Resident 191 required hemodialysis every Monday, Wednesday, and Friday from 1:30 PM to 5:30 PM. During a concurrent observation and interview 11/26/2024 at 10:01 AM with Licensed Vocational Nurse (LVN) 2 in Resident 191's room, LVN 2 could not find the emergency kit in Resident's 191's bedside drawers or closet and stated Resident 191 should have the emergency kit but did not. LVN 2 stated the purpose of the emergency kit was to have it available to the residents quickly during emergencies and the dressings inside the kit would be used to stop any potential bleeding from the resident's dialysis site. During a concurrent interview and record review on 11/27/2024 at 7:00 AM with Director of Nursing (DON), the facility's policy and procedure (P&P) Hemodialysis Access Care, dated 9/2010 was reviewed. The P&P indicated under Care Immediately Following Dialysis Treatment, 4. If there is major bleeding from the site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do no leave resident alone until emergency services arrive. DON stated the passage does not specifically mention an emergency kit, but it was necessary to have one at the bedside because the resident cannot be left alone if they begin to bleed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 14 of 23 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 11/27/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 20's fluoxetine (medication used to treat depression) had clinical justification as to why gradual dose reduction (GDR) was contraindicated and adequately define the indication for fluoxetine. This deficient practice had the potential to overmedicate Resident 20 with unnecessary medication. Findings: During a review of Resident 20's admission Record, (AR), the AR indicated Resident 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses included dementia (a progressive state of decline of mental abilities) with behavioral disturbance and mild, recurrent major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 20's Care Plan (CP, document that summarizes a resident's health conditions, specific care needs and current treatments) titled Resident is resistive to care and refusing care related to Dementia, dated 12/26/2023 the CP indicated interventions to give clear explanations of all care activities prior to and as they occur during each contact. The CP interventions further indicated if resident resists ADLs, reassure resident, leave, and return 5-10 minutes later and try again. During a review of Resident 20's Minimum Data Set (MDS -a resident assessment tool) dated 8/28/2024, indicated Resident 20 had severe cognitive (ability to think, reason, plan) impairment. The MDS, indicated Resident 20's mood did not have symptoms of feeling little interest or pleasure in doing things or feeling down, depressed, or hopeless. The MDS indicated Resident 20 did not have physical or verbal behaviors directed at self or others such as hitting, scratching, screaming, or disruptive sounds. The MDS indicated Resident 20 was dependent (helper does all the effort) for bathing and toileting hygiene. During a review of the consultant pharmacist's medication regimen review for Resident 20 Note to Attending Physician/ Prescriber, (NTAP) dated 9/16/2024, the NTAP indicated Resident 20 was due to be evaluated for a gradual dose reduction of fluoxetine. The NTAP further indicated the prescriber's response which was an x written into the checkbox labeled Agree. During a review of Resident 20's Order Summary Report, (OSR) dated with active orders as of 11/26/2024, the OSR, indicated to give fluoxetine 20 milligrams (unit of measurement) tablet orally once in the evening for depression manifested by refusal to participate with activities of daily living (ADL). During an interview on 11/27/2024 at 9:26 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 20 was mostly confused but did not show sad expressions or verbalize being sad. CNA 1 stated Resident 20 will sometimes refuse certain activities but will usually agree to them when asked again later. During an interview on 11/27/2024 at 9:56 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 15 of 23 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 11/27/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Resident 20 has dementia and sometimes refuses care such as getting changed. LVN 2 further stated LVN 2 didn't think Resident 20 had shown signs of depression and had not verbalized being sad, had sad expressions or crying. LVN 2 stated an example where Resident 20 did not want to be changed because Resident 20 stated it was cold. LVN 2 stated at that time after leaving Resident 20 and coming back at a later time, Resident 20 would agree to be changed. Residents Affected - Few During an interview on 11/27/2024 at 10:45 AM with Director of Nursing (DON), the DON stated during an informal conversation, Resident 20's prescriber did not want to reduce the current dose of fluoxetine as recommended by the consultant pharmacist but did not have any documentation from the prescriber to show why it would be clinically contraindicated. The DON stated the prescriber did not want to reduce the dosage of two psychotropic medications at the same time because the prescriber believed it (reduce the dosage) might lead to worsening behavior from Resident 20. The DON stated Resident 20's behavior included refusing care, refusing medication, and hitting staff. The DON stated the documentation from the prescriber is needed to justify why Resident 20 is contraindicated from a gradual dose reduction and to make sure the resident is not overmedicated. DON stated DON could not find documentation of non-pharmacological interventions used prior to starting Resident 20 on fluoxetine. The DON stated the indication for refusing to participate in ADL care was not clear and could be depression or another underlying cause. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 6/2021 the P&P indicated the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social, or environmental cause of the resident's behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 16 of 23 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 11/27/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs/medications used in the facility were labeled properly and/or discarded in accordance with professional standards of practice for one of two sampled medication carts (Med Cart 2). This deficient practice had the potential for residents to be administered (the act of giving a treatment, such as a drug, to a patient) with ineffective medications and potentially compromise the health, safety, and well-being of the residents. Findings: During a concurrent observation and interview on 11/26/24 at 11:02 a.m. with Licensed Vocational Nurse (LVN) 2 Med Cart 2 had the following stored: 1. Multiple opened house supply (over the counter) medications marked with an opened date (date medication was opened and used) stored in the first drawer except for an opened bottle of a Geri Care (brand name) Stool Softener 100 mg (milligrams, a unit of measurement) 200 Softgels with a manufacturer's expiration (exp) date of 2026/02 that was not marked with an opened date. 2. An opened bottle of Geri Care One-Day Multi-Vitamin 200 Tablets marked with an opened date of 8/14/24, with a manufacturer's exp date of 2025/11. 3. An opened box of Alka-Seltzer (brand name) Buffered aspirin (NSAID) Pain reliever/fever reducer 6 Effervescent Tablets (3 - 2 count pouches), not marked with an opened date, with a manufacturer's exp date of 2026/July. Inside the box, there were 3 pouches as follow: 1 unopened pouch with a manufacturer's exp date of 2026/[DATE], 1 unopened pouch with a manufacturer's exp date of 2026/[DATE], and 1 opened pouch with a manufacturer's exp date of 2026/[DATE] and 1 tablet inside the pouch. LVN 2 stated, staff did not have to date the house supply drugs with an opened date since staff followed the manufacturer's exp date. LVN 2 could not indicate a reason why all the opened house supply drugs stored in the first drawer of Med Cart 2 had an opened date and not the opened bottle of the Geri Care Stool Softener 100 mg 200 Softgels with a manufacturer's exp date of 2026/02 and the opened box of Alka-Seltzer Buffered aspirin (NSAID) Pain reliever/fever reducer 6 Effervescent Tablets (3 - 2 count pouches) with a manufacturer's exp date of 2026/Jul and inside the box were 3 pouches that included 1 unopened pouch with a manufacturer's exp date of 2026/[DATE], 1 unopened pouch with a manufacturer's exp date of 2026/[DATE] and 1 opened pouch with a manufacturer's exp date of 2026/[DATE] with 1 tablet inside. LVN 2 proceeded to put all 3 pouches back into it's box and returned the box in Med Cart 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 17 of 23 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 11/27/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/26/24 at 12:44 p.m. with the Director of Nursing (DON), the DON stated, labeling house supply drugs with an opened date and checking the manufacturer's exp date were part of the facility's protocol for house supply drugs. The DON stated, labeling with an opened date was important to ensure the house supply drugs were not past the recommended due date which was usually ninety (90) days from opening even though the manufacturer's exp date is ok to ensure the medication was still effective. During a concurrent observation and interview on 11/26/24 at 4:36 p.m. with LVN 6, the same opened box of Alka-Seltzer Buffered aspirin (NSAID) Pain reliever/fever reducer 6 Effervescent Tablets (3 - 2 count pouches) with a manufacturer's exp date of 2026/Jul and inside the box were 3 pouches that included 1 unopened pouch with a manufacturer's exp date of 2026/[DATE], 1 unopened pouch with a manufacturer's exp date of 2026/[DATE] and 1 opened pouch with a manufacturer's exp date of 2026/[DATE] with 1 tablet inside was stored inside Med Cart 2. LVN 6 stated, the opened pouch of Alka-Seltzer Buffered aspirin (NSAID) Pain reliever/fever reducer should have been discarded for infection control. LVN 6 stated, staff labeled house supply drugs with an opened date to let staff know when the house supply drugs needed to be replaced and to alert staff when the manufacturer's exp date is getting close. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised April 2019, the P&P indicated, all medications maintained in the facility were properly labeled in accordance with current state and federal guidelines and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 18 of 23 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 11/27/2024 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 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 personal beverages for employees were not stored in one of two kitchen refrigerators (Refrigerator 1). Residents Affected - Some This deficient practice had the potential for cross contamination and placed the residents at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 11/25/2024 at 9:35 AM with the Dietary Supervisor (DS) two Starbucks beverages with plastic open tops were observed in the refrigerator next to resident food items. The DS stated the two beverages belonged to employees and they should not be stored in the refrigerator due to the potential for cross contamination. During a review of the facility's policy and procedure (P&P) titled, Employee Meals, dated 2018, the P&P indicated food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 19 of 23 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 11/27/2024 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 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** B. During a review of Resident 11's AR the AR indicated, Resident 11 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with (acute) exacerbation (sudden flare-up), cellulitis (a common, potentially serious bacterial skin infection) of right lower limb and chronic kidney disease (progressive damage and loss of function in the kidneys). Residents Affected - Some During a review of Resident 11's History of Present Illness (H&P), dated 8/22/24, the H&P indicated, Resident 11 had decision making capacities. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 8/28/24, the MDS indicated, Resident 11's BIMS (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) Summary Score for cognitive (ability to think and process information) status was intact. During a review of Resident 11's Record of Controlled Substances (RCS), date received 10/21/24, the RCS indicated, a count of nine (9) tablets of Lorazepam 0.5 mg (milligrams, a unit of measurement). During a review of Resident 11's Order Summary Report (OSR), active orders as of 11/26/24, the OSR indicated, an order for Lorazepam Oral Tablet 0.5 mg Give 1 tablet by mouth every 4 hours as needed for anxiety. During a review of Resident 11's Medication Administration Record (MAR), dated 11/1/24 - 11/30/24, the MAR indicated, Resident 11 was administered (the act of giving a treatment, such as a drug, to a patient) Lorazepam 0.5mg tablet on 11/7/24, 11/17/24, 11/19/24 and 11/21/24. During a concurrent observation and interview on 11/26/24 at 11:02 a.m. with LVN 2, LVN 2 stated, the outgoing and incoming licensed staff would count the controlled drugs for accountability purposes. LVN 2 took out a Creative Living Medical (brand) pill counting tray kept inside Med Cart 2 and poured out Resident 11's Lorazepam tablets into the pill counting tray to verify the count. After LVN 2 verified the correct count of 9 tablets, LVN 2 poured the 9 tablets using the pill counting tray back into the Lorazepam's labeled bottle container then LVN 2 returned the pill counting tray back inside Med Cart 2 without cleaning before and after using the pill counting tray. LVN 2 stated, LVN 2 should have disinfected the pill counting tray before and after use for infection control. C. During a concurrent observation and interview with the HS on 11/26/24 at 1:17 p.m. with the HS, the screened-in section laundry room located outside on the east south side of the facility did not have a sink, hand soap, paper towels or alcohol hand-based sanitizer (AHBS, an over-the-counter hand sanitizer to use when soap and water are not readily available to lower the risk of spreading germs). The laundry room had a faucet about three (3) feet above the ground facing out of the laundry room. The HS Stated the facility washed and dried personal items for the residents. D. During a concurrent observation and interview on 11/26/24 at 1:29 p.m. with the HS outside of the laundry room, a staff (unnamed) came with boxes and the HS opened the lid (with HS's bare hand) of the large dumpster for the staff to throw the boxes into the dumpster. The HS did not perform hand hygiene after touching the dumpster. The HS stated the dumpster was for all the trash from the facility it's the dumpster. The HS stated, the HS should have washed the HS's hands but no sink here (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 20 of 23 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 11/27/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after touching the lid of the dumpster it's trash, of course, it's going to be dirty, we don't want germs. The HS stated, there should be at least an alcohol hand sanitizer available, but we wear gloves (referring to when sorting the dirty laundry). During an interview on 11/26/24 at 3:29 p.m. with the Infection Prevention Nurse (IPN), the IPN stated, it was important for staff to clean, wash or disinfect the counting pill tray before and after use for of course infection control. The IPN stated, the counting pill tray could have some residue left from the medication (in general) and potentially cause a drug interaction and/or allergy. The IPN stated, the HS should have performed hand hygiene after touching the trash dumpster for infection control and sanitary reasons. During an interview on 11/27/24 at 9:51 a.m. with the IPN, the IPN stated, staff should perform hand hygiene with soap and water or alcohol-based sanitizer such as after contact with residents even if staff wore gloves to prevent the spread of infection. The IPN stated, the laundry area had no sink for handwashing but should have at least a supply of hand sanitizer. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 9/18/23, the P&P indicated, the facility considered hand hygiene the primary means to prevent the spread of infections. The P&P indicated, hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) should be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The P&P indicated the use of gloves did not replace hand washing/hand hygiene. Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for 5 of 5 sampled residents (Residents 11, 23, 34, 241 and 242) by failing to ensure: A. The urinals were stored in shared restrooms for Residents 23, 34, 241 and 242 were properly labeled. B. Licensed Vocational Nurse (LVN) 2 disinfected (to thoroughly clean something by using a special chemical solution that kills germs like bacteria and viruses on a surface) the pill counting tray before and after use for Resident 11. C. Ensure the facility had sufficient hand hygiene supply and resources in the laundry area. D. Housekeeping Supervisor (HS) performed hand hygiene after touching the dumpster. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection to Residents 11, 23, 34, 241 and 242 and other residents and staff in the facility. Findings: A1. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 5/11/2024, with diagnoses including bacteremia (a condition where bacteria are present in the bloodstream), urinary tract infection (UTI, a condition in which bacteria invade and grow in the urinary tract), and difficulty walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 21 of 23 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 11/27/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 8/20/2024, the MDS indicated Resident 23 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 23 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. A2. During a review of Resident 34's AR, the AR indicated the facility admitted Resident 34 on 10/24/2024, with diagnoses including encephalopathy (a serious health problem that affects brain function or structure), type 2 diabetes mellitus (T2DM, a disease that occurs when your blood glucose [blood sugar], is too high), and chronic kidney disease (CKD, a condition where the kidneys are damaged and can't filter blood properly). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 had severe cognitive impairment. The MDS indicated Resident 34 was dependent with ADL and dependent with mobility. A3. During a review of Resident 241's AR, the AR indicated the facility admitted Resident 241 on 11/19/2024, with diagnoses acute kidney failure (AKI, is where your kidneys suddenly stop working properly), type 2 diabetes mellitus (T2DM, a disease that occurs when your blood glucose [blood sugar], is too high), and chronic kidney disease (CKD, a condition where the kidneys are damaged and can't filter blood properly), and lack of coordination. During a review of Resident 241's History and Physical (H&P), dated 11/20/2024, indicated Resident 241 had decision making capacity. The H&P indicated Resident 241 was independent with ADL. A4. During a review of Resident 242's AR, the AR indicated the facility admitted Resident 242 on 11/13/2024, with diagnoses including UTI, metabolic encephalopathy (a change in how your brain works due to an underlying condition), and muscle weakness. During a review of Resident 242's MDS, dated [DATE], the MDS indicated Resident 242 cognition was intact. The MDS indicated Resident 242 was dependent with ADL and required substantial/maximal assistance (helper does more than half the effort and helper lifts or holds trunk or limbs and provides more than half the effort) with mobility. During an observation on 11/25/2024 at 11:31 AM, two urinals were found unlabeled in the shared restroom for Resident 241 and Resident 242. During an observation on 11/25/2024 at 12:07 PM, two urinals were found unlabeled in the shared restroom for Resident 23 and Resident 34. During an interview on 11/25/2024 at 1:16 PM, with Certified Nurse Assistant (CNA) 3, CNA 3 stated that all urinals should be properly labeled with the Resident's initials and room number. CNA 3 stated that this (labeling the urinals) ensures the prevention of cross contamination of infectious diseases. CNA 3 stated that the urinals found in the shared restroom for Resident 23 and Resident 34 were not properly labeled. CNA 3 stated that the urinals found in the shared restroom for Resident 241 and Resident 242 were not properly labeled. During an interview on 11/26/2024 at 09:40 AM, with the Infection Preventionist Nurse (IPN), the IPN stated that all urinals should be easily identifiable and properly labeled with the resident's initials and room number. The IPN stated that this (labeling the urinals) avoids cross-contamination of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 22 of 23 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 11/27/2024 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 0880 harmful bacteria from person, object place to another. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, dated 9/26/2022, the P&P indicated that the purpose of the infection prevention and control program was established to maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555832 If continuation sheet Page 23 of 23