Health inspection·February 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete him to make sure he was safe. IDON also stated activities of daily living (ADL, tasks of everyday life which includes eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care for personal hygiene was to be done as soon as possible. The IDON stated all residents were supposed to be treated with dignity and respect all the time. A review of facility's policy and procedure (P&P) titled, Resident Rights - Accommodation of needs, revised 1/1/2012, indicated the facility environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well -being. Facility staff will assist residents in achieving these goals. Event ID: Facility ID: 055056 If continuation sheet Page 2 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission record indicated Resident 12 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included peripheral vascular disease (a condition in which a build-up of fat and narrowing of arteries in the limbs, reducing blood flow), anemia (a decrease in the total amount of red blood cells or hemoglobin in the blood), gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region (tailbone) stage 3 (full thickness tissue loss, fat may be visible, but bone, tendon, or muscle is not exposed). A review of Resident 12's H&P dated 1/24/2024 indicated Resident 12 has the capacity to understand and make decisions. A review of the MDS, dated [DATE], indicated Resident 12 required maximal assistance from staff members for transfers, toilet use, personal hygiene, and bathing. During an interview with the Administrator (Admin) on 2/13/2024 at 9:12 AM, Admin stated Resident 12 did not have a hard copy of the advance directive (a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself) inside the medical record and stated it should be uploaded in the system. Admin stated she did not know if the actual hard copy of the advanced directive should be in the medical chart as well. During interview and record review (RR) with Minimum Data Set (MDS) nurse on 2/13/2024 at 9:14 AM, MDS stated there was no copy of an updated advance directive in Resident 12's medical record. MDS nurse stated, there should be a hard copy of the advance directive inside the chart and also it should be uploaded in the computer. During an interview with Interim Director of Nursing (IDON) on 2/13/2024 at 9:25 AM, IDON stated the advance directive should be filed inside Resident 12's medical chart. IDON stated, it is important for the advance directive to be filed in the correct tab in the advance directive tab, that way the rest of the staff can easily find it in case there is an emergency. During interview with Social Service Director (SSD) on 2/13/2024 at 9:38 AM, SSD stated the advance directive was inside Resident 12's chart but the copy was not filed correctly inside the chart and should be under the advance directive tab. The advance directive was filed under the Social Service tab that is why they cannot find it. A review of the facilities P&P titled, Advance Directives, revised 7/2018 indicated, upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. Based on interview, and record review, the facility failed to provide the Resident's/ Resident's responsible parties' right to have a written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for two (2) of 2 sampled residents (Resident 4 and 12) for advance directive care area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 3 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0578 Level of Harm - Minimal harm or potential for actual harm 1. Resident 4 did not have an advanced directive or a signature declining information on how to obtain an advanced directive. 2. Resident 12 did not have a copy of advance directive filed under the advance directive tab in the resident's physical medical chart where staff can access during a medical emergency. Residents Affected - Some This deficient practice had the potential for violating Residents 4 and 12 choices about their medical care. Findings: 1. A review of the facility's face sheet indicated Resident 4 was admitted on [DATE] with diagnoses including muscle weakness, difficulty in walking, and hypertension (high blood pressure). A review of Resident 4's History and Physical (H&P) dated 9/4/2023, indicated that Resident 4 has capacity to make decisions. A review of Resident 4's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 12/11/2023, indicated Resident 4 had moderately impaired cognition (ability to understand and make decision). Resident 4 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity, helper assist only prior to or following the activity) with eating, oral hygiene, toileting, and personal hygiene. The MDS indicated advance directive was not completed. During a concurrent record review of Resident 4's electronic medical record and physical medical chart, and interview with SSD (Social Service Designee) on 2/13/2024 at 11:18 AM, SSD stated, she cannot find any records regarding Resident 4's advance directives. SSD stated, all residents should have an Advance Healthcare Directive Acknowledgement Form on their medical records. SSD stated, Resident 4 has no Advance Healthcare Directive Acknowledgement Form. SSD stated that advance directives is being discussed upon admission, during care plan meetings which is done quarterly and annually. During an interview with Registered Nurse (RN) 1, on 2/15/2024 at 9:41 AM, RN 1 stated resident's advance directives are written statement by resident, that facility needed to follow when resident can no longer make decisions. RN 1 stated the advance directives should be offered to the residents or the responsible party on admission. RN 1 stated when the residents or the responsible party refused the advanced directive, it should be indicated in the form with the date of refusal attached to their chart. RN 1 stated when the residents said they already had an advance directive, the facility should obtain a copy and add to their medical records. RN 1 stated informing residents about their options and offering information about directives is important because it is resident's right to have an advance directive. A review of facility's Policy and Procedure titled Advance Directives, revised in July 2018, policy indicated upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. It also indicated if a resident does not have an Advance Directive, the Facility will provide the resident and/or resident's next of kin with information about advance directives upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 4 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented for one of 20 sampled residents (Resident 174). This deficient practice placed Resident 174 at risk of not having goals and interventions to fulfill resident's needs which had the potential to negatively affect Resident 174's well-being. Findings: A review of Resident 174's admission Record, indicated resident was admitted to the facility on [DATE] with admitting diagnoses of urinary tract infection (UTI), bacteremia, and Klebsiella Pneumoniae (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions). A review of Resident 174's History and Physical, dated 2/08/24, indicated the resident had the capacity to understand and make decisions. During a concurrent interview and record review of Resident 174's electronic medical records on 2/13/2024 at 3 PM, with Minimum Data Set Nurse 2 (MDSN 2), MDSN 2 stated Resident 174 did not have baseline care plan, and that licensed nurses (LN) caring for Resident 174 should have initiated the baseline care plan. MDSN 2 stated baseline care plans were initiated within 48 hours upon admission to the facility. MDSN 2 stated that baseline care plan was important as it was a since it was required upon admission to determine the specific care and needs of the resident. Since it was required upon admission to determine the specific care and needs of the resident. During a concurrent interview and record review of Resident 174's electronic medical records on 2/13/2024 at 3:05 PM with Registered Nurse 1 (RN1), RN 1 stated admitting Resident 174 on 2/08/2024. RN 1 stated that he did not initiate the baseline care plan for Resident 174, and that RN 1 had never initiated or completed a baseline care plan for residents.RN1 stated Resident 1's baseline care plan should have been completed by 2/10/2024, however was never initiated. RN stated that baseline care plan was important to ensure Resident 174's immediate care needs were met. A review of facility's policy and procedure titled,Comprehensive Person-Centered Care Planning, revised November 2018, indicated baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. It also indicated that Baseline Care Plan Summary will be developed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 5 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for two (2) of 20 sampled Residents (Resident 4 and 18) as indicated on the facility's policy. 1. Resident 4's oxygen therapy order was not revised on 2/12/2024 when order was changed to as needed from continuous use. 2. Resident 18's care plan to prevent injury was not revised when Resident 18 was non compliant with the use of soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for residents with epilepsy (a disorder of the brain characterized by repeated seizures [abnormal brain activity]). This deficient practice had the potential for inconsistency of care being rendered for Residents 4 and 18, which could affect over all well-being. Findings: 1. A review of the facility's face sheet indicated Resident 4 was admitted on [DATE] with diagnoses including muscle weakness, difficulty in walking, and hypertension (high blood pressure). A review of Resident 4's History and Physical (H&P) dated 9/04/2023, indicated that Resident 4 had the capacity to make decisions. A review of Resident 4's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 12/11/2023, indicated Resident 4 had moderately impaired cognition. Resident 4 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity, helper assist only prior to or following the activity) with eating, oral hygiene, toileting, and personal hygiene. Resident 4 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing and putting on/taking off footwear. The MDS also indicated Resident 4 partial/moderate assistance with shower and lower body dressing. A review of Resident 4's Order Summary Report, indicated an order for oxygen 2 liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose), to keep oxygen saturation (amount of oxygen that's circulating in your blood) above 92% as needed for shortness of breath, with an order start date of 2/12/2024. During a concurrent interview and record review on 2/15/2024 at 9:44 AM, with Registered Nurse 1 (RN 1), Resident 4's care plan and active orders were reviewed. RN 1 stated Resident 4's care plan indicated continuous use of oxygen therapy, but since 2/12/24 the physician's order was changed to as needed. RN 1 verified that Resident 4's oxygen therapy care plan was not updated accordingly. RN 1 stated that updating or revising resident's care plans was important to ensure that the staff taking care of Resident 4 would have the knowledge about the type of care to provide to Resident 4. RN 1 stated that since Resident 4's oxygen order was as needed, her oxygen concentrator should just be on when Resident 4 needed to have oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 6 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/15/2024 at 11:45 AM, with the Interim Director of Nursing (IDON), Resident 4's care plan and active orders were reviewed. The IDON stated that Resident 4's oxygen therapy order was updated to as needed since 2/12/2024. The IDON stated Resident 4's care plan was not revised to as needed. A review of facility's policy and procedure titled Comprehensive Person-Centered Care Planning, revised in November 2018, purpose indicated to ensure that a comprehensive person-centered care plan is developed for each resident. It indicated that it is the policy of this Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. It indicated a procedure that additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems. ii. Change of condition. iii. In preparation for discharge. iv. To address changes in behavior and care; and v. other times as appropriate or necessary. 2. A review of Resident 18's admission Record indicated the facility admitted Resident 18 on 5/1/2023 with diagnosis which include muscle weakness, epilepsy, and lack of coordination. A review of Resident 18's MDS, dated [DATE], indicated Resident 18 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 18 required partial /moderate assistance (helper does more than half of the effort) on oral hygiene, upper body dressing, putting on / taking off footwear and personal hygiene. Resident 18 required substantial/ maximum assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) on toilet hygiene, shower / bathe self and lower body dressing. During a review of Resident 18's Order Summary Report, dated 6/25/2023 indicated the following: a. Monitor placement of soft helmet every shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 7 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0657 b. Place soft helmet on at all times, may remove during meals every shift. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 2/12/2024 at 11:44 AM., with Licensed Vocational Nurse 1 (LVN 1), in Resident 18's room, Resident 18 was observed in bed, not wearing a soft helmet, with the side rails padding (provides added cushioning to help reduce injuries) on the floor. LVN1 stated Resident 18 was on seizure precautions (safety measures taken before an individual experiences a seizure). LVN 1 stated Resident 18's side rails should be padded. LVN1 stated Resident 18 should always wear a soft helmet and should only be removed during mealtimes. Residents Affected - Few During concurrent interview and record review on 2/13/2024 at 2:43 PM., with the MDS assistant (MDSA), MDSA stated Resident care plans should be person centered and that it was important to follow care plan to prevent accident or harm to residents. MDSA stated Resident 18's care plan for high risk for falls and injury related to seizure disorder, initially dated 5/2/2023, indicated Resident with episodes of removing helmet despite education of risk. The same care plan was revised on 6/25/23 with interventions to provide reminders to keep soft helmet on at all times, educate benefits of the use of helmet while having seizure- to protect Resident from injury or death. MDSA stated Resident 18's care plan should have been revised since care plan interventions were ineffective, and that resident care plans were revised every three (3) months. During interview on 2/15/2024 at 12:48 PM., with the interim director of nursing (IDON), IDON stated when care plans are not effective, licensed nurses are required to revise or update the resident's care plan. A review of facility's policies and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised date, 11/2018 indicated to ensure that a comprehensive care plan is developed for each resident. The policy also indicated to provide person centered, comprehensive and interdisciplinary care that reflects best standards for meeting heath safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial wellbeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 8 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 Based on interview and record review, the facility failed to provide one (1) to 1 feeding assistance (help residents in a nursing facility eat and drink) while eating for 1 of 1 sampled resident (Resident 34) for ADL care area, as indicated on the physician's order. Residents Affected - Few This deficient practice had the potential for Resident 34's functional ability to decline, suffer a weight loss, and risk for accident such as choking, which coould result to harm. Findings: A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 2/12/2019. Resident 34's diagnoses included muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection), and dysphagia (swallowing difficulties). A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 2/2/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 34 required partial /moderate assistance (helper does less than half the effort) with eating. Resident 34 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) with oral hygiene, toilet hygiene, lower body dressing, and personal hygiene. During a review of Resident 34's Order Summary Report, dated 4/1/2022, indicated a physician's order for the resident to have a 1:1 feeding assistance with all meals. During a concurrent observation and interview on 2/12/ 2024 at 8:39 AM., in Resident 34's room with the licensed vocational nurse 2 (LVN 2), LVN 2 verified Resident 34 was on bed sleeping with food around his mouth and on his gown. Resident 34's food tray was observed left on Resident 34's bed side table. During concurrent observation and interview on 2/13/ 2024 at 8 AM., in Resident 34's room with Treatment Nurse (TN). TN verified Resident 34 was on bed sleeping with pureed egg all over his mouth and all over his gown. During interview on 2/15/ 2024 at 12:48 PM., with the interim director of nursing (IDON), the IDON stated activities of daily living (ADL, tasks of everyday life which includes eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care assistance should be provided to the residents to maximize the resident's ADL abilities. The IDON also stated it was important to follow doctors order for good care. A review of facility's policy and procedure (P&P) titled, Resident Rights- Quality of life, revised date 3/20/2017, indicated to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. The P&P also indicated each resident shall be cared for in the manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 9 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 observation, interview, and record review, the nursing staff failed to elevate bilateral lower extremities (BLE, everything from your hip to your toes, including your hip, thigh, knee, leg, ankle, foot, and toes) and implement care plan for one of 20 sampled (Resident 224). Residents Affected - Few This deficient practice had the potential to result in a delay in reducing the swelling in the affected extremities. Findings: A review of Resident 224's admission Record indicated the facility admitted Resident 224 on 2/1/2024 with diagnosis which include muscle weakness, difficulty in walking and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 224's Minimum Data Set (MDS, standardized care and screening tool), dated 2/8/2024, indicated Resident 224 was moderately impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 224 was substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) on eating, oral hygiene, toilet hygiene, shower / bathe self and lower body dressing and personal hygiene. A review of Resident 224's Order Summary Report for 2/4/2024, indicated on 2/4/2024 to elevate BLE on pillow every shift for bilateral feet edema (swelling caused by too much fluid trapped in the body's tissues) management for 21 days, order end date 2/25/2024. A review of Resident 224's Care Plan, initiated on 2/4/2024, indicated focus: bilateral feet edema and intervention to elevate BLE's on pillows when in bed. During a concurrent observation and interview with MDS assistant (MDSA) in the Resident 224's room at 2/14/2024 at 2:06 PM, Resident 224 was laying on bed with BLE flat, there was no pillow available at bedside. During interview on 2/15/2024 at 12:48 PM, with the interim Director of Nursing (IDON), IDON stated Resident 224 had BLE edema, BLE needs to be elevated for better circulation and to lessen the swelling. IDON further stated it was important to follow doctors order and care plan for good care. A review of Resident 224's Treatment Administration Record (TAR), dated 2/2024, indicated monitor edema of the right foot, document level of edema +1, +2, +3, +4 (Grade +1: up to 2 millimeters (mm, unit of measurement) of depression, rebounding immediately. Grade +2: 3-4mm of depression, rebounding in 15 seconds or less. Grade +3: 5-6mm of depression, rebounding in 60 seconds. Grade +4: 8mm of depression, rebounding in 2-3 minutes). The TAR indicated, on 2/14/2024 at 7AM shift +2 on right foot and + 2 on left foot. A review of facility's Policy and Procedure (P&P) titled, Resident Rights- Quality of life, revised on 3/20/2017 indicated purpose: to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 10 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure injury/ ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set up accurately for two (2) of three (3) sampled residents (Resident 12 and Resident 16) for pressure ulcer care area. Residents Affected - Some This deficient practice had the potential for the resident to worsen or develop new pressure injury. Findings: 1. A review of the admission record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region (tailbone). A review of Resident 12's history and physical (H&P) dated 1/24/2024 indicated Resident 12 has the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/30/2024, indicated Resident 12 was severely impaired in cognitive skills (process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making and required maximum assistance from staff for dressing, toilet hygiene, shower, and personal hygiene. Resident 12 required assistance in bed mobility. A review of Resident 12's Order Summary dated 1/23/2024 at 10:32 PM, indicated to monitor weight weekly x four (4) weeks every day shift every seven (7) days for 4 weeks. A review of Resident 12's care plan dated 1/25/2024, indicated Resident 12 had the potential for injury (bruises, skin tears, entrapment [trapped in between the mattress and bed rails]) related to the use of bedrails. Interventions were to ensure the beds dimensions are appropriate for the resident's size and weight and there are no gaps between the mattress, rail, and bedframe. The care plan indicated re-evaluate with any mattress change particularly low air loss mattresses. A review of Resident 12's weights and vitals summary dated 2/14/2024 at 11:14 AM, indicated Resident 12's weight as follows: On 2/07/2024 - 70.1 pounds (Lbs., unit of measurement) On 2/01/2024 - 71.1 Lbs. On 1/31/2024 - 71.1 Lbs. On 1/24/2024 - 73.4 Lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 11 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of Resident 12's low air loss mattress on 2/12/2024 at 9:21 AM, indicated the mattress was set to 150 Lbs. During an interview with LVN2 on 2/12/2024 at 9:26 AM, LVN2 stated, we set the LOL mattress by the resident's weight. LVN 2 also stated, the licensed nurses must do their rounds when they come in and make sure the LAL mattress setting on the bed is on and is set correctly. During an observation of Resident 12's low air loss mattress on 2/12/2024 at 1:30 PM, Resident 12's low air loss mattress was set at 150 Lbs. During an interview on 2/13/2024 at 8:54 AM, Treatment Nurse stated using a low air loss mattress was important for residents that have wounds especially those that are not ambulatory. Treatment Nurse stated, it is for preventative measure. 2. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), dysphagia (difficulty swallowing), and muscle weakness. A review of Resident 16's care plan focusing potential for injury, intervention indicated to ensure that the beds dimensions are appropriate for the residents, size and weight and there are no gaps between the mattress, rail, and bedframe. Re-evaluate with any mattress change particularly low air loss mattresses, initiated on 9/27/2022. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had severely impaired cognitive (thought process and ability to reason or make decisions) skills for daily decision making. Resident 16 was total dependent with one staff physical assist with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, eating, toilet use and personal hygiene. A review of Resident 16's care plan focusing the resident has potential for pressure ulcer development related to resident needs total staff assistance in bed mobility due to immobility, at risk for skin breakdown, at risk for developing pressure ulcers, with a goal that resident will have intact skin, free of redness, blisters, or discoloration. Interventions indicated the following: - Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated on 4/09/2023. - The resident requires Pressure relieving device on bed, LAL mattress for skin maintenance to be calibrated by resident's weight. Monitor for accurate setting every shift using (positive or negative (+/-) sign (+ meaning ACCURATE and- meaning INACCURATE) every shift, initiated on 6/30/2022 and revised on 10/23/2022. A review of Resident 16's Order Summary Report, dated 2/14/2024, indicated an order of low air loss mattress for skin maintenance to be calibrated by resident's weight. Monitor for accurate setting every shift using positive or negative (+/-) sign (+ meaning ACCURATE and- meaning INACCURATE) every shift, ordered on 4/07/2021. A review of Resident 16's weight summary, indicated Resident 16's latest weight on 2/01/2024 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 12 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0686 111.6 pounds (lbs, unit of measurement). Level of Harm - Minimal harm or potential for actual harm During a concurrent observation of Resident 16's LAL mattress in Resident 16's room, and interview with Restorative Nurse Assistant (RNA 1) on 2/13/2024 at 1:20 PM, RNA 1 stated Resident 16 is laying on a LAL mattress. RNA 1 stated that he does not know how to set and change settings of LAL mattress. RNA 1 stated, LAL mattress is set according to resident's weight. RNA 1 stated Resident 16's LAL mattress control unit indicated it was set at 185 pounds (lbs, unit of measurement). RNA 1 stated, Resident 16's weight has never been at 185 lbs and the resident's latest weight on 2/1/2024 was 111.6 lbs. RNA 1 stated that LAL mattress should be set according to resident's weight to provide the right pressure that is necessary for Resident 16. Residents Affected - Some During a concurrent observation of Resident 16's LAL mattress in Resident 16's room, and interview with Interim Director of Nursing (IDON) on 2/13/2024 at 1:25 PM, IDON stated Resident 16 is on LAL mattress for skin maintenance and LAL mattress should be set according to resident's weight, and licensed nurses, especially treatment nurses should be checking the LAL mattress periodically to make sure that the settings were correct, and the LAL was functioning right. IDON stated she was aware that Resident 16's LAL mattress was set at 185 lbs today and was set at 150 lbs yesterday because the mattress is sagging, and this can cause discomfort to the resident. During a concurrent record review of Resident 16 's medical records and interview with Registered Nurse (RN 1) on 2/15/2024 at 8:34 AM, RN 1 stated that Resident 16's LAL mattress order and care plan is to calibrate the mattress settings according to Resident 16's weight. RN 1 stated if a mattress is sagging, replacing it should have been the best solution rather than kept increasing pressure. A review of the facility's policy and procedure titled Pressure Injury Prevention, revised 9/01/2020 indicated the nursing staff will implement interventions identified in the care plan which may include, but are not limited to pressure redistributing device for the bed and chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 13 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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. Based on observation, interview, and record review, the nursing staff failed to ensure the safety of one of two sampled residents (Resident 18) by not ensuring Resident 18 was wearing a soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for people with epilepsy [uncontrolled shaking] ) and that had side rails remained padded (provides added cushioning to help reduce injuries). This failure had the potential to cause injury to Resident 18 during seizures (uncontrollable shaking). Findings: A review of Resident 18's admission Record indicated the facility admitted Resident 18 on 5/1/2023 with diagnosis which include muscle weakness, epilepsy and lack of coordination. A review of Resident 18's Minimum Data Set (MDS, standardized care and screening tool), dated 10/22/2023, indicated Resident 18 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 18 required partial /moderate assistance (helper does more than half of the effort) on oral hygiene, upper body dressing, putting on / taking off footwear and personal hygiene. Resident 18 required substantial/ maximum assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) on toilet hygiene, shower / bathe self and lower body dressing. During a review of Resident 18's Order Summary Report, dated 6/25/2023, indicated monitor padded side rails for proper placement and condition every shift. Notify maintenance for safety precaution. During a review of Resident 18's Order Summary Report, dated 6/25/2023, indicated monitor placement of soft helmet every shift. The order summary report dated 6/25/23 also indicated soft helmet on at all times, may remove during meals every shift. During a review of Resident 18's Care Plan, date initiated 5/2/2023, indicated the resident has a seizure disorder with interventions indicating soft helmet on at all times, may remove during meals. During an observation on 2/12/2024 at 9:02 AM., in Resident 18's room, Resident 18 was in bed with bilateral side rails (metal rails that normally hang on the side of the patient's bed) up. The right-side rail was not padded and Resident 18 was not wearing a soft helmet. During concurrent observation and interview on 2/12/2024 at 11:44 AM., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the Resident 18's side rail pad was on the floor, and only one side rail was padded. LVN1 stated since Resident 18 was on seizure precaution (safety measures taken before an individual experiences a seizure), both side rails should be padded. LVN 1 stated Resident 18 should be wearing the soft helmet, even in bed and should only be removed during mealtimes. During interview on 2/15/2024 at 12:48 PM., with the interim Director of Nursing (IDON), IDON stated side rails should be padded at all the time for the protection and safety of Resident 18. During a review of facility's policies and procedure (P&P) titled Resident Safety revised date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 14 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 4/15/2021 indicated purpose to provide a safe and hazard free environment. Policy indicated resident will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 15 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) for one of two sampled residents (Resident 34). This deficient practice had the potential to result in complications including infections and stomach discomfort. Findings: A review of Resident 34's admission Record indicated the facility admitted Resident 34 on 2/12/2019 with diagnosis which include muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection) and dysphagia (swallowing difficulties). A review of Resident 34's Minimum Data Set (MDS, standardized care and screening tool), dated 2/2/2024, indicated Resident 34 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 34 was partial /moderate assistance (helper does less than half the effort) on eating. Substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) oral hygiene, toilet hygiene, lower body dressing and personal hygiene. During concurrent observation and interview on 2/12/2024 at 8:39 AM, with the Licensed Vocational Nurse (LVN 2) LVN 2 stated Resident 34's G-tube [NAME] Valve was dirty, it was crusted. During interview on 2/15/2024 with the interim Director of Nursing (IDON), the IDON stated, G-tube [NAME] Valve are changed as needed, when soiled and when clogged. IDON also stated Resident 34's G-tube [NAME] Valve was dark brown to light brown in color and appears to have dry food residue. IDON also stated the nurse, or the treatment nurse should have assessed the G-tube every shift and changed if it is dirty and crusted. IDON further stated it is for infection control and it' was supposed to be sanitary. A review of facility's policy and procedure (P&P) titled, Infection Control, revised date 1/1/2012, indicated the facility's infection control policies and procedure are intended to facilitate maintaining safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 16 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) used in the administration of parenteral fluid (delivery of fluid or medication through an IV, subcutaneous [beneath, or under, all the layers of the skin], intramuscular [within or into the muscle] or mucosal [the moist, inner lining of some organs and body cavities] route to maintain adequate hydration, restore and/or maintain fluid volume, establish lost electrolytes [minerals in your blood and other body fluids that carry an electric charge], or provide nutrition which includes total parenteral nutrition [TPN, IV administered nutrition]) and left it inserted for more than 96 hours for one (1) of 20 sampled residents (Resident 174), in accordance with facility's policy and procedure. Residents Affected - Few This failure had the potential to put Resident 174 at risk for developing an infection and complications. Findings: A review of Resident 174's admission Record, indicated the resident was admitted to the facility on [DATE] with admitting diagnoses of urinary tract infection (UTI, an infection of the urinary tract), bacteremia (bacteria in the blood), and Klebsiella Pneumoniae (infections commonly occur among sick residents in healthcare settings who are receiving treatment for other conditions). A review of Resident 174's History and Physical, dated 2/8/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 174's Intravenous therapy (IVT) administration Record, indicated on 2/8/2024, the resident received meropenem (an antibiotic- medication used to treat bacterial infections) IV solution intravenously to resident's left forearm. A review of Resident 174's Order Summary Report. dated 2/14/2024, indicated an order to check IV site dressing and monitor for signs or symptoms of infection at site, every shift until 2/09/2024. During an observation and interview with Resident 174 on 2/14/2024 at 4:30 PM in Resident 174's room, Resident 174's left forearm IV site was observed wrapped. Resident 174 stated that his IV line was from the hospital and he came to the facility with it. Resident 174 stated that he received and completed the IV medication therapy at the facility last week. During a concurrent record review of Resident 174's IVT administration record and interview with Registered Nurse 1 (RN 1) on 2/14/2024 at 4:42 PM, RN 1 stated Resident 174's IV catheter saline lock on the left forearm was inserted before Resident 174's admission to the facility on 2/8/2024. RN 1 stated Resident 174 had an order from the General Acute Care Hospital (GACH) to continue meropenem (IV antibiotic, used to treat infection) IV therapy at the facility and on the evening of 2/8/2024 would have been the last dose. RN 1 stated he administered the last dose of Resident 174's antibiotic using the IV site on the resident's left forearm on 2/8/2024 at 10:13 PM. RN 1 stated that Resident 174's IV site should have been removed after the last dose of meropenem IV therapy on 2/8/2024 . RN 1 stated there was no physician order to keep IV site on the left arm after last dose of IV therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 17 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent a record review of Resident 174 nurses' active orders and interview with Interim Director of Nursing (IDON) on 2/14/2024 at 4:50 PM, IDON verified that Resident 174 had no active IV therapy order. The IDON stated that peripheral IV sites are changed every 72 hours to prevent having infection, and to only keep peripheral IV sites until end of IV therapy. During a concurrent observation of Resident 174 and interview with IDON and RN 1 on 2/14/2024 at 4:53 in Resident 174's room, RN 1 and IDON verified that Resident 174 has a left forearm peripheral IV. RN 1 stated that it was the same peripheral IV site where he administered the IV antibiotic on 2/8/2024. A review of facility's undated policy and procedure titled, Infusion Guidelines & Procedures, policy indicated IV cannulas shall be removed routinely after 72 hours of dwell time unless otherwise ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 18 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 125's admission Record indicated Resident 125 was admitted to the facility on [DATE]. Resident 125's diagnoses included pneumonia (an infection that affects one or both lungs) due to other gram-negative bacteria (resistant to multiple drugs and are increasingly resistant to most available antibiotics), severe sepsis (a serious condition in which the body responds improperly to an infection) with septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection), and enterocolitis due to clostridium difficile (a bacteria that causes diarrhea). Residents Affected - Some A review of Resident 125's H&P, dated 2/8/2024, indicated Resident 125 can make needs known but cannot make medical decisions. A review of Resident 125's MDS, dated [DATE], indicated Resident 125 required maximum assistance for oral hygiene, toileting hygiene, showers, and personal hygiene. A review of Resident 125's Care Plan, initiated 2/2/2024, indicated Resident 125 had altered respiratory status related to respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts) and was at risk for alteration of respiratory status related to resident with episodes of removing oxygen. Staff interventions did not indicate to monitor resident for episodes of removing oxygen. A review of Resident 125's Physician's Order, dated 2/2/2024 at 1:02 AM, indicated Oxygen at two liters per minute (LPM) via nasal cannula (a thin, flexible tube that goes around the head and into the nose that delivers oxygen), titrate (a test that determines the body's oxygen needs at rest and while exercising) to keep oxygen saturation at 95% and above every shift for Acute respiratory failure with hypoxia. During an observation of Resident 125 in Resident 125's room on 2/12/2024 at 9:26 AM, Resident 125's nasal cannula was on the floor next to the bed. The oxygen concentrator (a device that concentrates the oxygen to supply an oxygen-enriched product gas stream) was set to 1 1/2 Liters. During an interview with CNA1 on 2/12/2024 at 9:37 AM, CNA1 stated that Resident 125 was supposed to be on oxygen at all times. CNA1 stated, The charge nurse told me, he is usually on oxygen. During an interview with LVN on 2/12/2024 at 9:42 AM, LVN stated, He is supposed to have his nasal cannula on, he has it off. His oxygen does fluctuate (change continuously). If we take it off, he does not show signs of shortness of breath, but his oxygen level does go down. We always have to check that his oxygen saturation is 95-97%. Without the nasal cannula, his oxygen drops from 92% to 89%. It would be dangerous If he doesn't have his nasal cannula because since he is on contact precautions, it would take some time for the staff to put on PPEs (personal protective equipment) and check on him. We need to make sure he has it on all the time. During a concurrent observation and interview with LVN on 2/12/2024 at 9:51 AM, observed Resident 125's nasal cannula still on the floor. LVN confirmed Resident 125's nasal cannula was on the floor and stated, I have to check his oxygen because I don't know how long the oxygen has been off. Observed LVN checking Resident 125's drawers and stated, I usually have my vital sign equipment here, but right now I can't find it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 19 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's undated policy and procedure titled, Oxygen Therapy, revised 11/2017 indicated, Oxygen is administered under safe and sanitary conditions to meet residents needs. Licensed Nursing staff will administer oxygen as prescribed. Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for three (3) of 3 sampled residents (Resident 4, 125, and 224) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 4's oxygen humidifier (medical device used to humidify supplemental oxygen) and nasal cannula (a device that delivers extra oxygen through a tube and into your nose) tubing were not on the floor. Resident 4's oxygen concentrator was also left on when Resident 4 was not on oxygen therapy. 2. Resident 125 did not receive oxygen as indicated on the physician's order. 3. Resident 224's nasal cannula tubing and humidified sterile water was not properly labeled. These deficient practices had the potential to cause complications associated with oxygen therapy and increase the risk of infection to Residents 4, 125, and 224. Findings: 1. A review of the facility's admission record indicated Resident 4 was admitted on [DATE] with diagnoses including muscle weakness, difficulty in walking, and hypertension (high blood pressure). A review of Resident 4's History and Physical (H&P), dated 9/4/2023, indicated Resident 4 had capacity to make decisions. A review of Resident 4's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 12/11/2023, indicated Resident 4 had moderately impaired cognition (ability to understand and make decision). Resident 4 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity, helper assist only prior to or following the activity) with eating, oral hygiene, toileting, and personal hygiene. Resident 4 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing and putting on/taking off footwear. It also indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with shower and lower body dressing. A review of Resident 4's Order Summary Report, dated 2/15/2024, indicated a physician's order of oxygen 2 liters per minute via nasal cannula to keep oxygen saturation (measure of how well the lungs are working) above 92 percent (%) as needed for shortness of breath, with order date of 2/12/2024. During an observation in Resident 4's room on 2/12/2024 at 8:39 AM, Resident 4's oxygen concentrator (medical devices for oxygen therapy) placed on the right side of the resident's bed was observed to be turned on, while the oxygen humidifier and nasal cannula were observed on the floor. Resident 4 was in the toilet, and not using oxygen therapy at this time. During an observation in Resident 4's room on 2/13/2024 at 8:18 AM, Resident 4's oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 20 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concentrator placed on the right side of the resident's bed was observed to be turned on. Resident 4 was in the toilet, and not using oxygen therapy at this time. During a concurrent record review of Resident 4's physician's orders and interview with Registered Nurse 1 (RN 1) on 2/15/2024 at 9:45 AM, RN 1 verified that Resident 4's oxygen therapy order was as needed. RN 1 stated that Resident 4 will only receive oxygen therapy when resident's oxygen saturation is below 92% as indicated in the order. RN 1 added, Resident 4's oxygen saturation was obtained and Resident 4 should not be getting oxygen. RN 1 stated it was important to follow the physician's order for oxygen use and for the nurses to be given education regarding oxygen use. A review of facility's policy and procedure titled, Oxygen therapy, revised in November 2017, indicated to ensure the safe storage and administration of oxygen in the facility. Policy indicated oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Procedure indicated administration of oxygen: Administer oxygen per physician orders. The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. Procedure also indicated Oxygen - Storage, Maintenance, and Handling: -Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. -Humidifier equipment will be maintained and/or changed per manufacturer's guidelines or no more than every 7 days. They will be dated each time they are changed. A review of facility's policy and procedure titled Oxygen safety and handling, created October 21, 2021, indicated a purpose to understand and comply with the proper safety and handling regulations for the use of oxygen and oxygen cylinders to ensure Resident safety. 3. A review of Resident 224's admission Record indicated the facility admitted Resident 224 on 2/1/24. Resident 224's diagnoses included muscle weakness, difficulty in walking, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 224's MDS, dated [DATE], indicated Resident 224 was moderately impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 224 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) with eating, oral hygiene, toilet hygiene, shower / bathe self, lower body dressing, and personal hygiene. During observation on 2/12/24 at 8:49 AM., in Resident 224's room, the oxygen humidified ( increase the level of moisture) sterile water was dated 2/1. There was no year indicated. The nasal canula (a device that delivers extra oxygen through a tube and into the nose) tubing was dated 2/6/24. During concurrent observation and interview on 2/13/24 at 8:09 AM., with the treatment nurse (TN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 21 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0695 Level of Harm - Minimal harm or potential for actual harm the TN stated the oxygen humidified water was dated 2/1 and the nasal canula nasal canula tubing was dated 12/12. The TN stated there was no year indicated on the humidified water and the nasal cannula tubing. The TN also stated the facility changes the nasal canula and humidified water as needed or every five (5) to seven (7) days. TN further stated it was important to date the humidified water and nasal cannula tubing properly so the facility staff will know when they have to change it. Residents Affected - Some During a review of Resident 224's Order Summary Report, dated 2/4/24 indicated oxygen inhalation at two (2) liters (L, unit for measuring the volume of a liquid or a gas) per minute via nasal cannula. During interview on 2/15/24 at 12:48 PM., with the interim director of nursing (IDON), the IDON stated the oxygen humidified sterile water and nasal cannula need to be changed as needed or weekly, based on the date indicated on the humidified sterile water and nasal cannula for infection control. A review of facility's policy and procedure (P&P) titled Infection Control revised date 1/1/2012 indicated the facility's infection control policies and procedure are intended to facilitate maintaining safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 22 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to ensure the daily nurse staffing information (list of total number of staff and the actual hours worked by the staff to meet this regulatory requirement) was placed in a visible and prominent place that is readily accessible to the residents and/ or visitors on 2/12/2024 and 2/14/2024. Residents Affected - Many As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. Findings: During an observation on 2/12/18 at 7:41 AM, no visible daily nurse staffing information posting was found at the facility lobby or at either one of the two Nursing Stations. During an interview with Director of Staff Development (DSD) on 2/14/2024 at 12:46 PM, DSD stated she was not aware of the location of where the daily nurse staffing information was posted including the facility name, date, census, and the total number of actual hours worked per shift for licensed and unlicensed staff responsible for resident care. During an interview with the Administrator (Admin) on 2/14/2024 at 1:21 PM, Admin stated, the form (daily nursing staffing form) is usually posted on the consumer board (located at the back of the facility), we typically just place it there, this is the form we use. During an observation on 2/14/2024 at 1:26 PM, the Daily Nurse Staffing form was posted at the back of the facility near the kitchen area and across the activity room, at the bottom of a board mounted on the wall. Observed the daily nurse staffing form was blocked from site by kitchen food/tray carts parked in front of it. During a concurrent observation and interview with the Admin on 2/14/2024 at 1:29 PM, Admin stated the daily staffing form they had posted at the back of the facility and should have been posted where it is visible and readily accessible to the residents and/ or visitors. Admin also added the daily staffing form should have the correct information, it indicated total actual hours for 3 PM to 11 PM to be a total of 100.5 hours but it was just 1:29 PM so there should not be actual hours et for 3 PM to 11 PM shift. Admin also stated, this is what we have assigned, this is our form, we have always used it. A review of the facility's policy and procedure titled Nursing Department-Staffing, Scheduling & Postings, revised 7/2018, indicated it was the policy of the facility to post the data in a prominent place readily accessible to residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 23 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) and built up spoon (specialized utensil with built up handle designed to assist residents with limited or weakened grasping strength) during meal, as indicated on the physician's order, for one of one sampled resident (Resident 39) in Activities of Daily Living care area. Residents Affected - Few This deficient practice placed Resident 39 at risk for further decline in physical functioning and decline to perform self-feeding skills. Findings: A review of Resident 39's admission Record indicated the resident admitted to the facility on [DATE] and got readmitted on [DATE], with diagnoses including but not limited to cerebral infarction (stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 39's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/2/2023, indicated Resident 39 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). Resident 39 required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, lower body dressing, and putting on/taking off footwear. Resident 39 was dependent (helper does all the effort) with toileting hygiene, shower, and upper body dressing. A review of the Resident 39's Summary Report indicated a Physician's Order dated, 1/2/2024 for a plate guard and built-up spoon for all meals. A review of Resident 39's Care Plan, initiated on 3/28/2023 indicated Resident 39's swallowing problem related to difficulty with thin liquids. Staff intervention included for Resident 39 to eat only with supervision. A review of Resident 39's Care Plan, initiated on 1/12/2024, indicated Resident 39's impaired activity of daily living skills due to further decline in physical functioning. The goal indicated Resident 39 will be able to perform self-feeding skills with supervision to stand by assist with use of plate guard and built-up spoons. During an observation on 2/12/2024 at 12:22 PM, Resident 39 was in dining room and was being fed by staff. Resident 39's meal tray was observed to have a plate guard and red colored utensils, which was different from other residents' utensils. Staff was observed holding the red colored utensils and the plate guard while feeding Resident 39. During a concurrent observation in the dining room and interview with Certified nurse assistant 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 24 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CNA 3) on 2/14/2024 at 12:20 PM, Resident 39 was being fed by CNA 3. Resident 39's meal tray was observed to have a plate guard and red colored utensils which was different from other residents' utensils. CNA 3 stated that she needed to feed Resident 39 because resident usually makes a mess when he eats by himself. CNA 3 stated that Resident 39's spoon is heavy and special, unlike another resident's spoon. During a concurrent observation in the dining room and interview with Dietary Staff Supervisor (DSS) on 2/14/2024 at 12:25 PM, DSS stated that Resident 39 has an order to have a plate guard and weighted utensils during meals. DSS verified that CNA 3 was the one using the weighted spoon while feeding Resident 39. DSS stated that Resident 39 was supposed to use the spoon and the plate guard and not CNA 3. During a concurrent record review of Resident 39's Physician's orders and interview with Occupational Therapist 1 (OT 1) on 2/15/2024 at 10:45 AM, OT stated that Resident 39 has an order for plate guard and built-up spoon for all meals since 1/2024. OT 1 stated that Resident 39 need these assistive devices during meals because Resident 39 has the tendency to have shaky hands due to Parkinson's disease. OT 1 stated that this assistive device would promote Resident 39's ability to self-feed and for independence. OT 1 stated that if Resident 39 was unable to use the assistive device during meals, nurses should communicate it to them so an evaluation could be conducted for appropriateness of Resident 39's assistive devices during meals. OT 1 stated that she was not aware that Resident 39 was being assisted by staff during meals. A review of facility's policy and procedure titled, Adaptive Equipment-Feeding devices, revised 7/1/14, indicated adaptive feeding equipment is used by residents who need to improve their ability to feed themselves and in order to enable residents with physically disabling conditions to improve their eating functions. Procedure indicated occupational therapist, when possible, will determine the usefulness of adaptive equipment and notify the dietary and nursing departments when it is to be discontinued. And types of adaptive Equipment are the ff: A. Built-up silverware B. Built-up dish with inner lip C. Special cups D. Special cups and glass holders E. Plate guards FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 25 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent food contamination and the spread of foodborne illness as indicated on the facility policy when the facility failed to ensure: 1. The sanitary storage and disposal of expired food. These deficient practices have the potential to result to pathogen (germ) exposure and place residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to hospitalizations. 2. Seven (7) of 32 kitchen mounted ceiling lights have a protective plastic cover. This deficient practice had the potential of breakage with particles of glass potentially landing on food preparation areas or residents' trays. Findings: During observation on 2/12/2024 at 07:52 AM., in the kitchen were multiple food containers noted with expired date labels. a. A partially covered silver color pan with partially defrosted chicken with expired used by label was observed in the bottom shelf of the refrigerator. b. A silver color pan with ground beef with expired used by label was observed in the bottom shelf of the refrigerator. c. One opened unsealed box of Shredded [NAME] Wheats cereal was observed in the pantry room. During a concurrent observation and interview on 2/12/2024 at 8:02 AM. with Dietary Supervisor (DS), in the kitchen, DS confirmed the following were observed in the refrigerator: a. Apple Sauce container marked with only one date 02/11/2024 (the date was not specific if it was an opened date or used by date) b. Black Beans container, dated 2/6/2024 and use by date of 2/9/2024 c. [NAME] color diet Jello container, dated 2/7/24 and use by date of 2/10/2024 d. Diet Pudding container, dated 2/8/2024 and use by date of 2/11/2024 e. Enchilada Sauce container, dated 2/6/2024 and use by date of 2/8/2024 f. Partially uncovered pan with partially defrosted uncovered chicken, dated 2/8/24 and use by date 2/11/2024 DS stated, All the food that are expired should be thrown away. The chicken should be covered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 26 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 completely and thrown away. The opened cereal box should be thrown away. It belonged to a resident that was discharged . DS stated the residents can get sick if they are served expired food. During concurrent observation and interview with Maintenance Director (DM) on 2/14/2024 at 10:39 AM., MD confirmed the mounted ceiling lights did not have a protective plastic cover to protect the bulbs. Residents Affected - Some During concurrent observation and interview with DS on 2/14/2024 at 10:48 A.M., DS stated, I was not aware the lights should have protective covers. DS stated, Glass pieces can fall on the food. During a review of the facility's policy and procedure titled, Food Storage, revised 7/25/2019, it indicated that the purpose was to establish guidelines for storing, thawing (change from a solid, frozen state to a liquid or soft one, because of an increase in temperature), and preparing food. a. Food items will be stored, thawed, and prepared in accordance with good sanitary practice. b. All items will be correctly labeled and dated. c. Thawing: Thaw foods at 41 degrees Fahrenheit or below in covered container in refrigerator. Thaw meat by placing it in deep pans and setting it on lowest shelf in refrigerator. Develop guidelines detailing defrosting procedure for different types of food. d. Date meat when taken out of freezer and with date of meal service. e. Dry storage guidelines. Any opened products should be placed in storage containers with tight fitting lids. During a review of the facility's policy and procedure titled, Maintenance Service, revised 1/1/2012, indicated that the purpose was to protect the health and safety of residents, visitors, and facility staff. It indicated that the maintenance Department maintains all areas of the building, grounds, and equipment. Functions of the Maintenance Department may include, but are not limited to: 1. Maintain the building in compliance with current federal, state and local laws regulations, and guidelines. 2. Maintain the building in good repair and free of hazards. 3. Establishes priorities in providing repair service. 4. Providing routinely scheduled maintenance service to all areas; and other services that may become necessary or appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 27 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when Dietary Aid was observed dumping four(4) clear bags of kitchen trash on top of the regular facility trash at the the facility's parking area on the North/East side of the facility building on 2/14/2024 Residents Affected - Some This failure had the potential to result in the attraction and spread of vermin (animals that are believe to be harmful, or that carry diseases, e.g., rodents parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility. Findings: During an observation on 2/14/2024 at 11:19 A.M. in the kitchen, Dietary Aid (DA) was observed taking out 4 bags of kitchen trash to the the facility's parking area on the North East side of the facility building. DA was observed dumping the trash bags from the kitchen on the ground with the rest of the facility's regular trash that were also pile on the ground. There were bags containing personal protective equipment (PPE), chucks, diapers and other miscellaneous trash observed on the ground. There were no garbage and refuse containers noted at the location. During a concurrent observation and interview on 2/14/2024 at 11:19 A.M, Dietary Supervisor (DS) stated, Trash should not be out like that. This is an infection control issue. Vermin can get into the trash. Maintenance is in charge of the trash. During a concurrent observation and interview on 2/14/2024 at 1:44 PM, Maintenance Director (MD) stated trash is picked up by the City on Monday, Wednesday, Thursday, and Saturday but this problem with the trash bags piling up on the ground happens each day the trash is picked up because all the trash bins are placed outside. MD added, Once the trash bins are brought back, the pile of trash bags on the ground gets put into the trash bins, but the problem happens again the next day. I know that's not good but that's what happens. MD stated, It the city's responsibility to pick up the trash and they have no extra bins to place the trash in while waiting for the trash bins to be brought back. During a concurrent observation and interview on 2/14/2024 at 3:07 P.M. with Infection Control Nurse (ICN), ICN stated, Trash bags should not be on the ground. Trash bags should be kept in trash bins until the trash bins are back from the city. During record review of the facility's policy and procedure titled, Waste Management, dated 4/21/2022, indicated, To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. Procedure: 1. Maintain appropriate regulated waste containers. Containers must be: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 28 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0814 CLOSABLE, puncture resistant, and leak proof Level of Harm - Minimal harm or potential for actual harm b. Labeled with biohazard symbol or color coded in red Residents Affected - Some c. Located in holding areas such as the soiled utility room and other designated areas as needed. 2. Food waste will be placed in covered garbage and trash cans. a. Waste will be disposed of in garbage cans following local city codes. b. Plastic liners should be used in clean garbage and trash cans to eliminate spillage and reduce garbage and trash can washing time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 29 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 13 out of 35 rooms (5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23) met the square footage requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This deficient practice has the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents. Findings: During the initial observation on 2/12/2024, from 9 AM to 10:20 AM, Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23 did not meet the minimum requirement of 80 sq. ft. per resident. The residents in these rooms were able to ambulate freely and/or maneuver in their wheelchairs freely. Nursing staff had enough space to provide care to these residents with dignity and privacy. There was space for beds, side tables, dressers, and other medical equipment. During an interview with the Director of Nursing (DON) on 2/12/2024 at 11:15 AM, the DON stated that the administrator would submit a room wavier for these resident rooms room [ROOM NUMBER], 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23. A review of the facility's room waiver dated 2/12/2024, indicated, there was enough space for each resident's nursing and the health and safety of the residents occupying these rooms. The room waiver indicated these rooms were in accordance with the needs of the residents and would not have an adverse effect on the residents' health and safety or impede the ability of any resident to attain his or her highest practicable well-being. The room waiver showed the following: Room Sq. Ft. Beds room [ROOM NUMBER]- 226.9 sq. ft. - 3 beds room [ROOM NUMBER]- 222.24 sw. ft - 3 beds room [ROOM NUMBER]- 226.9 sq. ft. - 3 beds room [ROOM NUMBER]- 222.24 sq. ft. - 3 beds room [ROOM NUMBER]- 226.9 sq. ft. - 3 beds room [ROOM NUMBER]- 222.24 sq. ft. - 3 beds room [ROOM NUMBER]- 221.9 sq. ft. - 3 beds room [ROOM NUMBER]- 221.9 sq. ft. - 3 beds room [ROOM NUMBER]- 221.9 sq. ft. - 3 beds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 30 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0912 room [ROOM NUMBER]- 221.9 sq. ft. - 3 beds Level of Harm - Potential for minimal harm room [ROOM NUMBER]- 221.9 sq. ft. - 3 beds room [ROOM NUMBER]- 216.26 sq. ft. - 3 beds Residents Affected - Some room [ROOM NUMBER]- 216.26 sq. ft. - 3 beds The minimum square footage for 3-bed rooms is 240 sq. ft. During interviews with residents both individually and collectively, they did not express any concerns regarding the size of their rooms. The Department would be recommending the room waiver for Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23 as requested by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 31 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment when multiple piles of trash bags were observed on the ground near the facility's parking area on the North/East side of the facility building. This failure had the potential to result in the attraction and infestation of vermin (wild animals that are believed to be harmful such as rodents, parasitic worms or insects) that could potentially infiltrate the facility, affect resident care areas and pose a direct disease and infection threat to residents. Findings: During an observation on 2/14/2024 at 11:19 A.M., multiple piles of trash bags along with other miscellaneous trash such as a broken folding chair, plastic bucket, two wooden crates, empty cardboard boxes, and a gurney were observed on the ground near the facility's parking lot area on the North/East side of the facility building. There were no trash garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) containers noted at the site. The trash bags were a mixed of regular facility trash with disposed Personal protective equipment (PPE, equipment used to prevent or minimize exposure to hazards), diapers, chucks (pads to protect the bed) , and trash bags from the kitchen disposals. During a concurrent observation and interview on 2/14/2024 at 11:19 A.M, Dietary Supervisor (DS) stated, Trash should not be out like that. This is an infection control issue. Vermin can get into the trash. Maintenance is in charge of the trash. During a concurrent observation and interview on 2/14/2024 at 1:44 PM, Maintenance Director (MD) stated trash is picked up by the City on Monday, Wednesday, Thursday, and Saturday but this problem with the trash bags piling up on the ground happens each day the trash is picked up because all the trash bins are placed outside. MD added, Once the trash bins are brought back, the pile of trash bags on the ground gets put into the trash bins, but the problem happens again the next day. I know that's not good but that's what happens. MD stated, It the city's responsibility to pick up the trash and they have no extra bins to place the trash in while waiting for the trash bins to be brought back. During a concurrent observation and interview on 2/14/2024 at 3:07 P.M., the Infection Control Nurse (ICN) stated, Trash bags should not be on the ground, trash bags should be kept in trash bins until the trash bins are back from the city. During record review of the facility's policy and procedure titled, Pest Control, dated 1/1/2012, it indicated its purpose to ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors. It indicated procedures were: a. Garbage and trash are not permitted to accumulate in any part of the facility. b. Garbage and trash are removed from the facility as needed, and at lest once daily. c. The Maintenance Department assists, when appropriate and necessary, with pest control services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 32 of 33 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 055056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 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 0921 Level of Harm - Minimal harm or potential for actual harm During record review of the facility's policy and procedure titled, Waste Management, dated 4/21/2021, indicated a purpose to reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. It indicated to maintain appropriate regulated waste containers. Containers must be: a. CLOSABLE, puncture resistant, and leak proof. b. Labeled with Biohazard symbol or color coded in red. It indicated the food waste will be placed in covered garbage and trash cans. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 33 of 33