Health inspection·February 7, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Supervisor to fix it. RN stated the equipment in the facility needed to be in good condition at all times for the safety of all the residents. RN also stated it would be unacceptable for a resident to use damaged equipment since it could place the resident at risk of harm. During a concurrent interview with Resident 36 on 2/4/2025 at 11:16 AM, Resident 36 stated he had been asking staff to take him outside, but they told him the facility does not have a wheelchair big enough for him, so he stays in bed all the time. Per Resident 36, the Occupational Therapy Staff (OT) did attempt to transfer him to a wheelchair, but the wheelchair was too snug (something is too tight or fits too closely). Resident 36 stated he felt upset because it has been over a month when the facility staff told him they were working on getting a larger wheelchair so he can go outside, and the facility still has not received it. During an interview with Certified Nursing Assistant 5 (CNA 5) on 2/5/2025 at 9:37 AM, CNA5 stated she had cared for Resident 36 often and had not seen a wheelchair large enough for Resident 36 inside or outside the room. Per CNA5, Resident 36 would remain in bed and was not transferred to a wheelchair to go to the patio. During an interview with Social Service Director (SSD) on 2/5/2025 at 9:45 AM, SSD stated that Resident 36 did mention about needing a wheelchair his size but that she would have to confirm with the doctors' orders and make sure the wheelchair would be part of the Durable Medical Equipment (DMEs) to process through Home Health (medical services provided in a patient's home rather than in a hospital or other healthcare facility) upon Resident 36's discharge. During a follow up observation and interview with SSD on 2/5/2025 at 9:58 AM, SSD stated Resident 36 did have a wheelchair inside his room for his own personal use. Upon further inspection of Resident 36's room, SSD confirmed there was no such wheelchair inside the room. SSD then stated the wheelchair was stored away inside the storage room. Upon further inspection there was no large size wheelchair inside storage room. SSD then proceeded to state that the wheelchair was outside in the patio area. Upon further inspection of the patio area, SSD showed a wheelchair that was ripped, old, and dusty and stated that was the wheelchair that was provided for Resident 36's use. SSD did at that time confirm the wheelchair should be in better condition without any rips or dirt on it in order for Resident 36 to use. During an interview and record review with OT on 2/5/2025 at 10:15 AM, OT stated, In terms of his level on how much he can assist, he is max assist times 2 to sit at edge of bed. He used a Hoyer Lyft (a mechanical device that helps caregivers move people with limited mobility) at home. We have attempted to transfer him from bed to chair but he said the wheelchair was too snug for him. We were increasing sitting tolerance but the wheelchair we found was too snug we wanted to look for another wheelchair wider for his comfort but was not sure if they did. During a concurrent interview with the DON on 2/7/2025 at 4:08 PM, the DON stated Resident 36 should have a proper size wheelchair to accommodate his needs. The DON also stated, It is not acceptable for a resident to use a wheelchair that is damaged such as being ripped, old or dirty. If a resident was to use a damaged wheelchair it could cause potential danger like an accident and if it was dirty, it could harbor bacteria. During a review of the Housekeeper/Janitor Job Description, the description indicated Principal Responsibilities: Perform tasks to ensure a safe, comfortable and sanitary environment for all residents, staff and visitors according to established policies and procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 2 of 32 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 02/07/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Service, revised 1/1/2012, the P&P indicated its purpose to protect the health and safety of residents, visitors, and Facility staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: Residents Affected - Few II. Functions of the Maintenance Department may include, but are not limited to: D. Maintaining the heat/cooling system, in good working order. During a review of the facility's P&P titled, Resident Rights-Accommodation of Needs, revised 1/1/2012 indicated its purpose to ensure that the Facility provides an environment and services that meet residents' individual needs. Procedure: IV. In order to accommodate residents' needs and preferences, the Facility may make adaptations to the physical environment, including the residents'' bedroom and bathroom as well as the common areas in the Facility. Examples of such adaptations may include: D. Providing a variety of types (for example, chairs with and without arms) sizes, (height and depth), and firmness of furniture in rooms and common areas so that the residents with varying degrees of strength and mobility can independently arise to standing position. V. In order to accommodate residents' individual needs and preferences, Facility Staff attitude and behavior are directed towards assisting the resident's in maintaining independence, dignity and well-being to the extent possible according to residents' wishes. During a review of the facility's titled, Infection Control-Policies & Procedures, revised 1/1/2012 indicated its purpose to provide infection control policies and procedures required for a safe and sanitary environment. I. The Facility's infection control policies and procedures apply equally to all Facility Staff, consultants, contractors, residents, visitors, volunteer works, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. II. Objectives: A. Prevent, detect, investigate, and control infections in the Facility B. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. D. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard precautions. F. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 3 of 32 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 02/07/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71 to 81-degree Fahrenheit (° F-a unit of temperature measurement on the Fahrenheit scale, where water freezes at 32 degrees Fahrenheit and boils at 212 degrees Fahrenheit) for three (3) of eleven (11) sampled residents (Resident 126, Resident 63, and Resident 36). This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: 1. During a review of the admission record, the admission record indicated Resident 126 was initially admitted to the facility on [DATE], with diagnoses that included but not limited to nondisplaced fracture (a broken bone where the pieces of the bone remain aligned) of greater trochanter (a bony projection on the upper part) of right femur (thing bone), subsequent encounter for closed fracture with routine healing (encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase), protein-calorie malnutrition (a condition that occurs when someone does not get enough protein and calories in their diet. It can range from mild weight loss to severe wasting), muscle weakness, and history of falling. During a review of Resident 126's Minimum Data Set (MDS - resident assessment tool), dated 11/20/2024, the MDS indicated Resident 126 does not have impaired cognitive skills for daily decision making. Resident 126 needed partial to moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as toileting hygiene and upper body dressing and required substantial/maximal assistance (helper does more than half the effort) for shower, lower body dressing, and personal hygiene. During a review or Resident 126's Care Plan indicated Resident 126 is at risk for insomnia related to difficulty sleeping at night. Interventions indicated to monitor for factors that may contribute to poor sleep pattern. During an observation and interview with Resident 126 on 2/4/2025 at 9:04 AM, Resident 126's was inside an isolation room (a room that separates residents with infections or conditions that make them susceptible to infection from others) with the door closed. Resident 126 was observed to be sitting up in bed and was noticeably sweating and attempting to fan herself with her hands. Resident 126's hair was wet and sticking to her face and neck and her gown was noticeably wet from her torso (central part of the body that includes the chest, abdomen, back, and pelvis) area. Resident 126 stated, The temperature inside the room was terrible this morning. It was like a sauna (a special heated room in which people sit or lie down in order to get hot and sweat). It was really hot. Then I heard the thermostat (a device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) outside click off and it cooled off a bit. During a concurrent interview with Resident 126 on 2/4/25 at 9:14 AM, Resident 126 stated, You think it's hot now, you should have seen how hot it was earlier this morning. I had sweat all over myself and my door was closed. I didn't get any fresh air. Usually, I am not able to sleep well, and with how hot the room was, I could not go to sleep at all last night, it was too hot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 4 of 32 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 02/07/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm During an observation and interview with Maintenance Staff on 2/4/2025 at 9:22 AM, Maintenance Staff confirmed Resident 126's room was hot by measuring the temperature at 92 degrees Fahrenheit. Maintenance Staff stated that resident's rooms should be kept anywhere from 72 degrees Fahrenheit to 73 degrees Fahrenheit to keep them comfortable. Maintenance Staff stated, I will have to go and change the thermostat and put it to 73 to74 degrees. Residents Affected - Some During an observation of Maintenance Staff and Resident 126 on 2/4/2025 at 9:24 AM, Maintenance Staff asked Resident 126 if the room was too hot for her. Resident 126 once again stated the room was really hot and to please keep the room cooler since it was very uncomfortable, and her door was kept closed. 2. During a review of the admission record, the admission record indicated Resident 63 was initially admitted to the facility on [DATE], with diagnoses that included but not limited to acute kidney failure (a short-term condition where the kidneys can't filter waste from the blood), protein-calorie malnutrition, muscle weakness, difficulty in walking, history of falling, heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs). During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 does not have impaired cognitive skills for daily decision making, and needed substantial/maximal assistance (helper does more than half the effort) from the staff for the activities of daily living such as showers, upper and lower body dressing. During an observation and interview with Resident 63 on 2/4/2025 at 9:29 AM, Resident 63 was inside an isolation room with the door closed. Resident 63 was observed to be sitting up in bed. Resident 63 stated he was very uncomfortable inside the room because the room was too hot. 3. During a review of the admission record, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses that included but not limited to polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition where the body has trouble using sugar [glucose] from food properly and as a complication of the diabetes, there is nerve damage affecting multiple nerves throughout the body), end stage renal disease (irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), dysphagia, oropharyngeal phase (a swallowing difficulty that occurs in the mouth and throat when food or liquid moves from the mouth to the throat). During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 does not have impaired cognitive skills for daily decision making. Resident 36 needed partial to moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as eating and oral hygiene and substantial/maximal assistance (helper does more than half the effort) for dressing, toilet and personal hygiene. During an observation and interview with Resident 36 on 2/4/20205 at 9:32 AM, Resident 36 was sitting up in bed. Observed Resident 36's bed next to window. Observed window to be opened about one third of the way. Resident 36 stated he was upset because the room was really uncomfortable and very hot. Resident 36 stated, It's really hot in here. I have told multiple staff and it's still very hot. I told the Maintenance Supervisor over a week ago. I also told the Certified Nurse Assistant, the Nurse Supervisor and anyone that will come in here. They always say they will check but it's still very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 5 of 32 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 02/07/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hot all the time and on top of that, they want to keep the door closed. Even if I have the window open, it's hot all the time. And I'm not talking just a little hot, it's so hot that I feel like I have fever During a concurrent observation and interview with Maintenance Staff on 2/4/2025 at 9:46 AM, Maintenance Staff tested the temperature inside Resident 63 and Resident 36's room. Maintenance Staff stated he had already regulated the thermostat and the temperature inside Residents room was now 78 degrees. During an interview with Infection Control Nurse (IP) on 2/4/2025 at 9:49 AM, IP stated Maintenance Supervisor had not arrived at the facility yet but that he is the one responsible for the temperatures in the facility and even if the doors are closed, he can monitor the temperatures from his phone. IP stated, If the residents have a grievance (complaint or protest), we text him and he can lower the temperature automatically. During a concurrent observation and interview with IP on 2/4/2025 at 9:50 AM, observed IP walk inside Resident 63 and Resident 36's room and asked the residents if it was too hot inside the room. Both residents stated it was. Resident 36 also stated, You guys ask all the time and just leave but nothing gets done. It's still too hot and on top of that you want to keep the door closed. IP explained to both residents that they were in isolation and they had to maintain the door closed. Resident 36 responded to IP that he had been asking multiple staff many times to fix the temperature and it's still very hot. During an interview with Maintenance Supervisor on 2/4/2025 at 10:18 AM, Maintenance Supervisor stated he had checked the temperature for Resident 63 and Resident 36's room and it indicated it was at 75 degrees. Maintenance Supervisor stated, I can control the thermostat from my cell phone when it's over 81 degrees the app (an application, especially as downloaded by a user to a mobile device) will notify me. Maintenance Supervisor stated rooms 1 to 4 were considered one unit (single thing, a standard measurement, or a part of a larger whole) and he was not notified by the app that any of the rooms were at 92 degrees. During a concurrent interview with Maintenance Supervisor on 2/4/2025 at 10:21 AM, Maintenance Supervisor stated that the temperature inside the residents' rooms should not be set at 92 degrees. The range for inside the residents' room should be 71 to 81 degrees because that is within the range for the resident's comfort. Maintenance Supervisor also stated that the way to measure the temperature inside a resident's room is to use a temperature gun that is called Raytek. Maintenance Supervisor also confirmed that he did receive a call 2/3/2025 at 5:02 PM when he was at home from Resident 63 who was complaining that the room was very hot. During a review of the facilities Policy and Procedure (P&P) titled, Resident Rooms and Environment, revised 1/1/2012, the P&P indicated its purpose to provide residents with a safe, clean, comfortable and homelike environment. The Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Procedure: 1. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 6 of 32 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 02/07/2025 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 0584 F. Comfortable temperatures Level of Harm - Minimal harm or potential for actual harm During a review of the Housekeeper/Janitor Job Description, the description indicated Principal Responsibilities: Perform tasks to ensure a safe, comfortable and sanitary environment for all residents, staff and visitors according to established policies and procedures. Residents Affected - Some During a review of the facilities P&P titled, Maintenance Service, revised 1/01/2012, the P&P indicated its purpose to protect the health and safety of residents, visitors, and Facility staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: II. Functions of the Maintenance Department may include, but are not limited to: D. Maintaining the heat/cooling system, in good working order. During a review of the facilities P&P titled, Resident Rights-Accommodation of Needs, revised 1/1/2012, the P&P indicated its purpose to ensure that the Facility provides an environment and services that meet residents' individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 7 of 32 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 02/07/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure two (2) of five (5) sampled residents (Residents 66 and 225) were provided a communication board (a device that displays photos, symbols or illustrations to help people with limited language skills express themselves) that was readily accessible in the language the residents understood. Residents Affected - Few This failure had the potential to result in Residents 66 and 225 experiencing a delay in receiving appropriate care and treatment and feeling misunderstood due to the staff not being able to properly communicate with the resident. Findings: 1.During a review of Resident 66's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dementia (a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, reasoning and judgement) and muscle weakness (lack of muscle strength that makes it hard to move muscles). During a review of Resident 66's History and Physical Examination (H&P), dated 11/27/2024, H&P indicated resident does not have the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2024, the MDS indicated the resident was dependent (helper does all the effort; resident does none of the effort to complete the activity) with rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), personal hygiene and eating. During a review of Resident 66's Care Plan dated 12/3/2024, the Care Plan indicated Resident 66 was dependent on staff for meeting emotional, intellectual, physical and social needs and has a language barrier. Resident 66's care plan also indicated interventions including ensuring that adaptive equipment that the resident needs is provided and is present and functional - communication board or translator. During an observation on 2/4/2025 at 10:10 AM in Resident 66's room, no communication board was observed hanging on the wall near the resident's bedside, head of bed or on top of her nightstand. During an observation on 2/5/2025 at 8:33 AM in Resident 66's room, no communication board was observed hanging on the wall near the resident's bedside, head of bed on top of her nightstand. During a concurrent observation and interview on 2/5/2025 at 3:02 PM with Certified Nursing Assistant 1 (CNA 1) in Resident 66's room, no communication board was observed hanging on the wall near the resident's bedside, head of bed or on top of her nightstand. CNA 1 stated Resident 66 does not speak English and that there was no communication board hanging near the resident's bedside or on top of or inside her nightstand. CNA 1 stated when communicating with Resident 1, CNA 1 would make gestures (a movement of part of the body, especially a hand or the head, to express an idea or meaning or motions) to Resident 1. CNA 1 stated there should be a communication board readily available at the bedside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 8 of 32 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 02/07/2025 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 Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 225's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of wedge compression fracture (a break in the front of a vertebra [the bones that make up the spine] in the spine that causes the bone to collapse into a wedge shape) of thoracic 11 (T11; middle section of the spine which consists of 12 vertebrae) to thoracic 12 (T12) and muscle weakness. Residents Affected - Few During a review of Resident 225's MDS, dated [DATE], the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 225 was dependent with putting on footwear, needed substantial/maximal assistance (helper does more than half the effort) with upper and lower body dressing, needed partial/moderate assistance (helper does less than half the effort) with rolling left and right in bed and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. During a review of Resident 225's Care Plan dated 1/28/2025, the Care Plan indicated Resident 225 had a language barrier with her primary language and basic English. The Care Plan indicate interventions including to ensure adaptive equipment that the resident needs is provided and is present and functional communication board or translator. During an observation on 2/4/2025 at 11:08 AM in Resident 225's room, no communication board was observed on or around the resident's bedside, hanging on the wall or on top of her nightstand. During an observation on 2/5/2025 at 8:43 AM in Resident 225's room, no communication board was observed on or around the bedside, hanging on the wall or on top of her nightstand. During a concurrent observation and interview on 2/5/2025 at 2:35 PM with CNA 2 in Resident 225's room, no communication board was observed on or around the resident's bedside, hanging on the wall or on top of her nightstand. CNA 2 stated that there was no communication board readily accessible near the resident or inside Resident 225's nightstand. During an interview on 2/5/2025 at 2:44 PM with Resident 225, Resident 225 stated facility staff did not use any communication board in Resident 225's language to communicate with Resident 22, nor were there many staff in the facility who could speak Resident 225's primary language. Resident 225 stated speaking very little English and would try to communicate to staff her needs through body language and gestures. Resident 225 further stated that there has been a lot of misunderstandings with staff when she tries to communicate with them. During a concurrent interview and record review on 2/7/2025 at 1:42 PM with Director of Nursing (DON), the facility's policy and procedure (P&P) titled Accommodation of Residents' Communication Needs revised March 2017 was reviewed. The P&P indicated: a. The staff will assess the residents' ability to communicate at the time of admission and as needed. b. The staff will interact with the resident to observe and listen to his/her efforts to communicate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 9 of 32 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 02/07/2025 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 c. Level of Harm - Minimal harm or potential for actual harm Staff will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. Residents Affected - Few d. The following are examples of adaptive devises the staff may provide the resident: a. Communication boards/charts. The DON stated for residents who have a language barrier or who have limited English proficiency, a communication board or translator must be utilized so that the resident could communicate their needs to the nurses and staff. The DON stated when communication boards are not readily accessible, it places the resident at risk for being unable to clearly express their needs or wants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 10 of 32 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 02/07/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide grooming services for two (2) of five (5) sampled residents (Resident 53 and Resident 57) who were dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. Residents Affected - Few This deficient practice resulted in Resident 53 and 57's unkempt and dirty fingernails potentially leading to skin injury, infection, and scarring. Findings: 1.During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was initially admitted to the facility on [DATE] with diagnosis which included sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (swallowing difficulties) and muscle weakness. During a review of Resident 53's Annual History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 53 does not have the capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2024, the MDS indicated Resident 53's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 53 was dependent on personal hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing /drying face and hands. During a review of Resident 53's care plan initiated on 2/6/2025, the care plan indicated The resident has an ADL self-care performance deficit related to dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). The care plan indicated Resident 53 was totally dependent on staff for personal hygiene. The care plan interventions indicated to provide personal hygiene/ oral care. During an observation on 2/4/2025 at 11 AM in Resident 53's room, Resident 53's fingernails were observed dirty and crusted (having or forming a hard top layer or covering). During a concurrent observation and interview on 2/6/2025 at 12:25 PM with licensed vocational nurse 3 (LVN 3), LVN 3 stated Resident 53's nails were dirty, with blackish and yellowish discoloration inside the nail bed. LVN 3 also stated when resident nails are dirty, nails could harbor bacteria. 2. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was initially admitted to the facility on [DATE] with diagnosis which included dysphagia (swallowing difficulties), muscle weakness and paraplegia (the inability to voluntarily move the lower parts of the body). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skills for daily decision making was severely impaired. The MDS also indicated Resident 57 required substantial maximal assistance (helper does half the effort) on eating. Resident 57 was dependent on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 11 of 32 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 02/07/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing /drying face and hands). During a concurrent observation and interview on 2/4/2025 at 9:33 AM in Resident 57's room, Resident 57's was observed eating breakfast in bed, with the assistance of the Restorative Nurse Assistant 1 (RNA, helps residents regain ability to perform daily tasks). RNA 1 stated, Resident's (Resident 57) fingernails had dry crusted yellowish blackish color stuff on the pinky finger. During an interview on 2/7/2025 at 1:42 PM with the administrator (ADM), ADM stated it was not acceptable for residents to have dirty fingernails. The ADM stated the facility's policy and procedure was to clean residents' hands when dirty, before and after meals to prevent the spread of disease and infection. During a review of facility's Policies and Procedures (P&P) titled, Clean Hands, dated 2/27/2024, indicated Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics (medications used to treat bacterial infections) and protects healthcare personnel and patients. The P&P also indicated steps to take when patient and visitors should clean their hands which included before preparing or eating food. During a review of facility's P&P titled, Hand Hygiene, revised 9/1/2020, the P&P indicated The facility considers hand hygiene as primary means to prevent the spread of infection. During a review of facility's P&P titled, Resident rights- accommodation of needs, revised 1/1/2012 indicated Purpose was to ensure that the facility provides an environment and services that meet residents' individual needs. The facility's environment was designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. The facility staff will assist residents in achieving these goals. The P&P also indicated the facility staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident's dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 12 of 32 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 02/07/2025 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 post the accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) in a prominent location (accessible to residents and visitors) in accordance with the facility's policy and procedure by failing to: Residents Affected - Some 1. Post the nurse staffing information in a prominent location on 2/4/2025. 2. Ensure the Daily Nurse Staffing Form (nurse staffing information) posted on 2/5/2025 was accurate to reflect the correct date and total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. These deficient practices have the potential for residents and visitors not to be informed of the facility census and staffing. Findings: During initial observation of the facility's entrance and lobby on 2/4/2025 at 8:02 AM, the Nurse Staffing Information, dated 2/4/25 was observed posted only in the red zone (nursing station 1, area for residents tested positive for Coronavirus [COVID-19, a severe infection mainly respiratory disease that could spread from person to person]). The Nursing Staff Information was not visible to other residents or visitors in the facility who were outside of the red zone nursing station 1. During a concurrent observation and interview on 2/5/ 2025 at 6:10 AM with the administrator (ADM), ADM stated the Daily Nurse Staffing form posted in the lobby was not updated. The Daily Nurse Staffing indicated a date of 2/4/2025, therefore the Daily Nurse Staffing was inaccurate. During an interview on 2/7/2025 at 1:29 PM with the ADM, ADM stated on the first day of the survey, the Daily Nurse Staffing form was posted in the red zone (nursing station 1) and was not accessible to the staff, residents, and visitor from the yellow zone (area for residents exposed to covid) and green zone (residents who are not exposed (nursing station 2). ADM also stated based on the facility's policy, the Daily Nurse Staffing should be accessible to all staff, residents and visitors, and must be accurate. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Department- Staffing, Schedule & Postings, revised 7/2018, indicated its purpose was to ensure the adequate number of nursing personnel are available to meet resident needs. Staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs, and such information will be posted as required. The P&P, under Nurse Staffing Postings, indicated the facility will post the following information daily: i. facility name. ii. the current date, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 13 of 32 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 02/07/2025 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 iii. Level of Harm - Potential for minimal harm the total number and actual hours worked by the following categories of licensed and unlicensed nursing staffing directly responsible for resident care per shift. Residents Affected - Some The P&P, under Posting Requirements, indicated the facility will post the nurse staffing data on a daily basis at the beginning of each shift and the data must be posted as follows: a. Clear readable format b. 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 14 of 32 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 02/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of six sampled residents (Resident 64) by failing to administer the resident's amlodipine 5 mg (milligrams - unit of measure, used to treat high blood pressure) one tablet and Vitamin C 500 mg one tablet, as indicated on the physician order. This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death. Findings: During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including, cardiomegaly (an enlarged heart), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]. During a review of Resident 64's Minimum Data Set (MDS- resident assessment tool), dated 11/27/24, indicated Resident 64 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS also indicated Resident 64 required partial/moderate assistance (Helper does less than half the effort) from staff for eating, toileting hygiene, and personal hygiene. During a review of Resident 64's Order Summary Report for February/2025, included the following prescribed orders: 1. amlodipine Besylate oral tablet 5 mg, ordered start date 11/28/2024 - give one tablet by mouth for hypertension (HTN). Hold for systolic blood pressure (SBP) less than (<) 110mmHg (a unit of measurement for pressure that stands for millimeter of mercury), scheduled administration time 9 AM. 2. Vitamin C 250 mg, ordered start date 12/6/2024 - give one tablet by mouth in the morning for supplement, scheduled administration time 9 AM Vitamin C 250mg During a Med Pass observation with the Licensed Vocational Nurse 2 (LVN 2) at the East Nursing Station on 2/6/2025, at 10:18 AM, LVN 2 prepared and administered the following oral (by mouth) medications for Resident 64: 1. amlodipine 5 mg one tablet. 2. Vitamin C 500 mg one tablet as supplement. During a concurrent review of Resident 64's Medication Administration Record (MAR) and interview with LVN 2 on 2/6/2025, at 10:25 AM, LVN 2 stated Resident 64 was administered 2 medications, amlodipine 5 mg and Vitamin C 500 mg on 2/6/2025 at 10:18 a.m. (1 hour and 18 minutes after scheduled administration time of 9 AM). LVN 2 stated both medications were scheduled to be given at 9 AM. LVN 2 stated, he was late passing medications to Resident 64 because he was answering another resident call light during Med Pass. LVN 2 stated failure to administer the medications timely in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 15 of 32 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 02/07/2025 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 0755 the physician's order could possibly result in hospitalization. Level of Harm - Minimal harm or potential for actual harm During an interview with the Administrator (ADM) on 2/6/2025 at 11:23 AM, ADM stated the facility's licensed nurses were supposed to pass medication to the residents within 1 hour before or within 1 hour after the scheduled time of medication administration. ADM stated the nurse may pass medications starting at 8 AM until 10 AM for medications scheduled for administration at 9 AM. Residents Affected - Few During a review of the facility's policy and procedures (P&P) titled, Medication Administration, revised 1/1/2012, the P&P indicated, medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. The seven rights of medication are: i. The right medication ii. The right amount iii. The right resident iv. The right time v. The right route vi. Resident has right to know what the medication does . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 16 of 32 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 02/07/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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 its medication error rate was less than five percent (5%). There were two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 7.69% for one (1) of six (6) sampled residents (Resident 64) observed during medication administration (med pass). 2 medications were not given within one hour from the scheduled 9 a.m. time. Residents Affected - Few This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death. Findings: During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including, cardiomegaly (an enlarged heart), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]. During a review of Resident 64's Order Summary Report for February/2025, included the following prescribed orders: 1. Amlodipine Besylate oral tablet 5 mg, ordered start date 11/28/2024 - give one tablet by mouth for hypertension (HTN) hold for systolic blood pressure (SBP) less than (<) 110mmHg (a unit of measurement for pressure that stands for millimeter of mercury), scheduled administration time 9 AM. 2. Vitamin C 250 mg, ordered start date 12/6/2024 - give one tablet by mouth in the morning for supplement, scheduled administration time 9 AM Vitamin C 250mg During a Med Pass observation with the Licensed Vocational Nurse 2 (LVN 2) at the East Nursing Station on 2/6/2025, at 10:18 AM, LVN 2 prepared and administered the following oral (by mouth) medications for Resident 64: 1. Amlodipine 5 mg (milligrams - unit of measure) one tablet (used to treat high blood pressure). 2. Vitamin C 500 mg one tablet as supplement. During a concurrent review of Resident 64's Medication Administration Record (MAR) and interview with LVN2 on 2/6/2025, at 10:25 AM, LVN 2 stated Resident 64 was administered 2 medications, amlodipine 5 mg and Vitamin C 500 mg on 2/6/2025 at 10:18 a.m. (1 hour) and 18 minutes after scheduled administration time of 9 AM). LVN 2 stated both medications were scheduled to be given at 9:00 a.m. LVN 2 stated, he was late passing medications to Resident 64, because he was answering call light during Med Pass. During an interview with the Administrator (ADM) on 2/6/2025 at 11:23 AM, ADM stated the facility's licensed nurses were supposed to pass medication to the residents within one hour before or within one hour after the scheduled time of scheduled medication administration. ADM stated the nurse may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 17 of 32 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 02/07/2025 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 0759 pass medications starting at 8 AM until 10 AM for medications scheduled for administration at 9 AM. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P) titled, Medication Administration, revised 1/1/2012, the P&P indicated, medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time. The seven rights of medication are: Residents Affected - Few i. The right medication ii. The right amount iii. The right resident iv. The right time v. The right route vi. Resident has right to know what the medication does . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 18 of 32 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 02/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to remove expired Osmolite 1.5 Cal (therapeutic nutrition that provide complete balanced nutrition for long- or short-term tube feeding for residents with increased calorie and protein needs.) from one (1) of two (2) Medication Rooms (Medication room [ROOM NUMBER]) located at nurse station 2. This deficient practice increased the risk for residents to receive nutrition that had become ineffective or toxic due to improper storage which could possibly lead to health complications resulting in harm and hospitalization. Findings: During an observation of the medication room with the Director Staff Development (DSD) on [DATE] at 2:23 PM, one (1) bottle of Osmolite 1.5 Cal was observed with the expiration date of [DATE]. During the same concurrent observation and interview on [DATE] at 2:43 PM, DSD stated, There should not be any expired enteral feeding bottle left in the medication room because if a licensed staff accidently administered it to the residents, they could get sick which could result in hospitalization. During an interview with the Director of Nursing (DON) on [DATE] at 3:12 PM, the DON stated the licensed staff should check the expiration date of the Osmolite 1.5 Cal before it is administered to residents. The DON stated licensed staff were responsible for ensuring medication and or enteral feeding bottle were not expired. The DON added, if it was expired, it should be properly discarded, and not be stored in the medication storage room. During a review of the facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], the policy and procedure indicated outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medications for medication disposal, and reordered from the pharmacy, if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 19 of 32 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 02/07/2025 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. Based on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean and sanitary manner and proper food handling was provided in accordance with the facility's policy and procedure(P&P) by failing to: 1.Ensure one can opener was sanitized and was not rusted (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) according to the facility's P&P titled, Can Opener Use and Cleaning. 2.Ensure [NAME] non- stick spray oil was properly covered with a lid. 3. Ensure cheese stored in the refrigerator was labeled with an open date or use by date (a calendar date that indicates when a product is best quality) and in a sealed container. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the 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 other serious medical complications and hospitalization. Findings: During an observation on 2/4/2025 at 7:44 AM in the facility kitchen, one can opener was observed rusted. During an observation on 2/4/2025 at 7:45 AM in the facility kitchen, [NAME] non -stick spray oil was observed without a lid. During an observation on 2/4/2025 at 7:52 AM in the facility kitchen, cheese was observed in the refrigerator that did not have a lid and did not indicate an open or use by date. During a concurrent observation and interview on 2/6/2025 at 8:48 AM with the dietary consultant (DC), DC stated the can opener was rusted. DC also stated there was a possibility for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) since the can opener was rusted. During a concurrent observation and interview on 2/6/2025 at 8:49 AM with the DC, DC stated [NAME] non- stick spray oil did not have a lid. During a concurrent observation and interview on 2/6/2025 at 8:50 AM with the DC, DC stated the cheese in the refrigerator was open and not properly sealed. The DC stated the cheese was unlabeled and did not have an open and use by date. DC also stated all containers should be sealed properly and labelled with an open and use by date. DC stated all containers should be sealed properly to prevent cross contamination, since dust and tiny insects could get into the food. During an interview on 2/6/2025 at 9:12 AM with dietary aid (DA), DA stated all containers must be covered and dated to prevent contamination from insects and/or tiny dust from being mixed into the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 20 of 32 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 02/07/2025 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 During a concurrent interview and record review on 2/7/2025 at 11:23 AM with the Director of Nursing (DON), the facility's P&P titled, Food Storage and Handling, dated 2022, was reviewed. The DON stated the P&P indicated that frozen cheese storage guidelines indicated to label and date all food items. The P&P indicated for foods in the dry storage area, that open products were placed in a storage container with tight fitting lids and to label and date all food items. The DON stated that the [NAME] nonstick oil spray should be covered, and the cheese container located in the refrigerator should be sealed properly, and should have a label indicating dates, to prevent food contamination, and identify if foods are expired. The DON stated labeling and dating foods were important to prevent sickness. During a concurrent interview and record review on 2/7/2025 at 11:24 AM with the DON, the facility's P&P titled, Can Opener Use and Cleaning revised 10/1/2014, was reviewed. The DON stated the P&P indicated the purpose was to establish guidelines for the use and cleaning of a can opener. The dietary staff will use the opener according to the manufacturer's guidelines. The P&P indicated the can opener would be sanitized between uses. The DON stated the can opener must be sanitized between uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 21 of 32 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 02/07/2025 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 ensure three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Waste Management.Policy and Procedure. Residents Affected - Some This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. Findings: During a concurrent observation and interview on 2/5/2025 at 6:40 AM with the Dietary Supervisor (DC), in the facility's parking lot, 3 dumpsters were observed. The dumpsters were overflowing with personal protective equipment (PPE- is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and kitchen trash. During a concurrent observation and interview on 2/6/2025 at 8:50 AM with DC, DC stated one dumpster in the facility's parking lot was observed. DC stated the dumpster was overflowing with used PPE and kitchen trash. DC stated dumpsters were not supposed to be overflowing, since it could attract insects, rats and could cause sickness, and was an infection control concern. During a concurrent interview with the Administrator (ADM) and record review of facility's Policies and Procedures (P&P) on 2/7/2025 at 1:11 PM titled, Waste Management, revised 4/21/2022, the ADM stated P&P's purpose was to reduce the risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. P&P also indicated to close the lid on biohazard containers (disease producing agents that can be transmitted to individuals through various routes of exposure [modes of transmission]. Exposure to these hazards may result in acute or chronic health conditions). P&P also indicated food waste will be placed in covered garbage and trash can. The ADM stated the facility was not compliant with the P&P, and that trashcans were supposed to be closed all the time for infection control. The ADM stated when dumpsters were left opened, and garbage was overflowing with kitchen waste, it may cause unpleasant odor and could attract insects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 22 of 32 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 02/07/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a coordination of care between the facility and hospice (a program that provides are and support for people who are nearing the end of their life) staff for one (1) of 1 sampled resident (Resident 64) in accordance with the facility's hospice program by not ensuring: a. Hospice staff visit progress notes were maintained in Resident 64's medical record. b. Hospice staff were signing in on their flow sheet in Resident 64's hospice binder. This failure resulted in Resident 64's medical record being inaccurate which had the potential for Resident 64 to not receive the required hospice care and services necessary to promote comfort and quality of life. Findings: During a review of Resident 64's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dissection of ascending aorta (a life-threatening condition where the inner layer of the ascending aorta [the part of heart that carries blood away from the heart to the rest of the body] tears and separates from the middle layer) and type 1 diabetes (a long term condition that affects the insulin [a hormone that helps regulate blood sugar levels] making cells of the pancreas [an organ located in the abdomen behind the stomach]). During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 12/2/2024, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills with daily decision making. Resident 64 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), personal hygiene and eating. During a review of Resident 64's Order Summary Report, dated 2/1/2025, Resident 64's Order Summary Report indicated an order for Resident 64 to be admitted under hospice for routine level of care. During a review of Resident 64's Care Plan, dated 2/4/2025, the Care Plan indicated Resident 64 had a terminal prognosis (an advanced stage of a medical condition for which a physician gave a prognosis of inevitable death in six [6] months or less) and to admit to hospice. Resident 64's Care Plan also indicated interventions including to work cooperatively with hospice team to ensure resident's spiritual, emotional, intellectual, physical and social needs are met. During a record review of Resident 64's Hospice Binder, dated 11/26/2024 to 2/7/2025, Resident 64's Hospice Binder indicated a calendar for December 2024, January 2025, and February 2025 indicating Registered Nurse (RN) visits from the hospice company to be once a week plus 1 to two (2) as needed (PRN) visits per week for symptom management during the entire benefit period starting 11/27/2024. The December 2024, January 2025, and February 2025 calendar also indicated Spiritual Counselor visits once a month plus 1 to 2 PRN visits per month for spiritual/emotional counseling/support during the entire benefit period starting on 11/28/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 23 of 32 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 02/07/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/7/2025 at 10:22 AM with the Administrator (ADM), ADM stated all hospice staff are supposed to sign in on the resident's hospice binder when they come in to see the residents. During a concurrent interview and record review on 2/7/2025 at 1:29 PM with the Director of Nursing (DON), Resident 64's hospice binder dated 11/26/2024 to 2/7/2024 was reviewed. Resident 64's hospice binder indicated no documentation of the hospice company's RN and Spiritual Counselor signing in to the flow sheet log when visiting Resident 64 and no progress notes from their visits from December 2024 to February 2025. The DON stated the hospice binder is considered a part of Resident 64's medical record and the binder contains the schedule of how often the resident is to be visited by specific hospice staff as well as their flow sheets in which the hospice staff are supposed to sign in on. The DON also stated the hospice staff's progress notes from their visits should be maintained in the hospice binder. The DON further stated because there is no documentation of the hospice RN and Spiritual Counselor signing in on their flow sheet in Resident 64's hospice binder as well as no progress notes from their visits from December 2024 to February 2025, Resident 64's medical record is inaccurate. During a review of the facility's policy and procedure (P&P) titled, Hospice Care of Residents, revised 1/1/2012, the P&P indicated under documentation, All documentation concerning hospice services will be maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 24 of 32 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 02/07/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia, lung inflammation usually caused by infection], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). Residents Affected - Some This failure had the potential to place the residents at risk for developing severe respiratory infection (pneumonia). Findings: During an interview on 2/6/2025 at 10:26 AM with Maintenance Supervisor (MS), MS stated that the way the facility control legionella at the facility is through their control measures and that to his knowledge, the facility does not do any sort of testing for legionella. During an interview on 2/6/2025 at 10:56 AM with MS, MS stated that they do not test for legionella. MS stated that they did not have an initial test and they do not do any sort of ongoing testing to confirm or validate that their control measures are working and stated it is because they are not required to test and, in his experience, they have not had any resident that was diagnosed with pneumonia caused by legionella. During an interview on 2/6/2025 at 12:37 PM with Infection Preventionist (IP), IP stated that she does not think they test for legionella or other waterborne pathogens but stated that she had suggested testing because that will be a validation if the facility's control measures are working or not. During a review of the facility's policy and procedure (P&P) titled Water Management revised 5/25/2025, the P&P indicated, The facility with develop and utilize water management strategies, using the Core Elements of a Water Management Plan (WMP), to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems, with its purpose, To minimize exposure to Legionella and other water-borne pathogens to our residents, family members, staff and visitors. The P&P also indicated under Control Measures and Corrective Actions: Following national, state and local guidelines, the team will identify needed control measures based on risk assessment performed, and how to monitor them and under Verification and validation: The team will ensure the program is running as designed and is effective. During a review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group letter titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), dated 6/2/2017, the letter indicated a review of the facility's policies and procedures and reports documenting water management implementation results to verify that facilities: A. Implement a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE, global organization that develops standards and guidelines for HVAC[heating, ventilation, and air conditioning] systems, indoor air quality, and energy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 25 of 32 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 02/07/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm efficiency) industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens. B. Residents Affected - Some Specify testing protocols and acceptable ranges for control measures and document the result of testing and corrective actions taken when control limits are not maintained. During a review of the CDC's toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated, Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called 'validation.' Environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program. Factors that might make testing for Legionella more important include: Being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires' disease. During a review of ASHRAE Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Systems, dated 6/23/2018, indicated the Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program is being implemented as designed. The resulting process is verification. The Program Team shall establish procedures to confirm, both initially and on an ongoing basis, that the Program, when implemented as designed, controls the hazardous conditions throughout the building water systems. The resulting process is validation. The Program Team shall determine whether testing for Legionella shall be performed and if so, how test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sampling frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented. The Program Team shall consider include the following as part of the determination of whether to test for Legionella: b. A health care facility provides in-patient services to at-risk or immunocompromised population. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 26 of 32 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 02/07/2025 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 of 35 resident rooms (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., unit of measurement) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care. Findings: During the initial observation on 2/4/2025 from 9:00 AM to 12:00 PM, Rooms 5, 7, 8, 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 and/or move around in their wheelchairs freely. Nursing staff were observed to have enough space to provide safe quality care and there was enough space for beds, side tables, dressers and other medical equipment. During a review of the facility's room waiver dated 2/4/2025, the facility's room waiver indicated the 13 rooms with three (3) beds are in accordance with the needs of the residents with adequate space and do not have any adverse effects on the residents' health and safety. The facility's room also indicated the following: Room Sq. Ft. 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] - 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 room [ROOM NUMBER] - 221.9 sq. ft. - 3 beds room [ROOM NUMBER] - 221.9 sq. ft. - 3 beds room [ROOM NUMBER] - 216.26 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 27 of 32 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 02/07/2025 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] - 216.26 sq. ft. - 3 beds Level of Harm - Potential for minimal harm The minimum square footage for a 3-bedroom is 240 sq. ft. Residents Affected - Some During an interview on 2/7/2025 at 2:20 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she has enough room for her to provide care to the resident's safely in all the resident's rooms including Rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23. During an interview on 2/7/2025 at 2:24 PM with CNA 4, CNA 4 stated that all the resident's rooms including Rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23 have enough room for her to provide proper and safe care to the residents. During interviews with residents in Rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23 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 28 of 32 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 02/07/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 two (2) of 17 sampled residents (Residents 8 and 44) had their call light (device used by residents to call staff) within reach. Residents Affected - Few This failure placed Residents 8 and 44 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. Findings: 1. During a review of Resident 8's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of type 2 diabetes (DM2; a disease in which one's blood sugar levels are too high) and dementia (a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, reasoning and judgement). During a review of Resident 8's History and Physical Examination (H&P), dated 11/20/2024, the H&P indicated the resident does not have the capacity to make their own decisions. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/23/2024, the MDS indicated the resident had severe impairment (difficulty with or unable to make decisions, learn, remember things) with cognitive skills for daily decision making. The MDS also indicated, Resident 8 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), personal hygiene and eating. During a concurrent observation and interview on 2/5/2025 at 8:26 AM with Certified Nursing Assistant 1 (CNA 1) in Resident 8's room, Resident 8's call light was observed hanging on the wall behind the left of the resident's head of bed. CNA 1 stated Resident 8's call light was hanging on the wall behind the head of the bed and not within the resident's reach. During an interview on 2/6/2025 at 9:25 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated a call light is a device residents use to alert staff if they need assistance and if it was not placed within the resident's reach, then the residents will not be able to communicate with staff that they need assistance, placing the reisdent at risk for falling. 2. During a review of Resident 44's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of metabolic encephalopathy (a brain disorder that occurs when there is an imbalance of chemicals in the blood) and multiple sclerosis (a long term autoimmune [occurs when the body's immune system mistakenly attacks its own healthy tissues] disease that affects the central nervous system [brain and spinal cord]). During a review of Resident 44's H&P, dated 12/28/2024, the H&P indicated the resident does not have the capacity to make decisions due to dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 29 of 32 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 02/07/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 44's MDS, dated [DATE], the MDS indicated the resident was dependent with rolling left and right in bed, upper and lower body dressing and personal hygiene. During a review of Resident 44's Care Plan dated 12/28/2024, the Care Plan indicated Resident 44 was at risk for falls and indicated interventions including to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Care Plan also indicated the resident needs prompt response to all requests for assistance. During a concurrent observation and interview on 2/4/2025 at 11:29 AM with LVN 2 in Resident 44's room, Resident 44's call light was observed wrapped around the back part of the resident's left upper side rail (a rail alongside of a bed connecting the headboard and footboard). LVN 2 stated Resident 44's call light was not within the resident's reach. LVN 2 stated the purpose of a call light is, so the residents are able to communicate their needs and if the call light is out of the resident's reach, then the staff would not be able to answer or address the needs of the resident. During an interview on 2/7/2025 with the Director of Nursing (DON), the DON stated a call light is for the resident's use to be able to call for help, call facility staff for what they need and if it is not within the resident's reach, then the resident would not be able to call the facility staff for help. The DON further stated if the resident is unable to call for help whether they are hungry or need to go to the bathroom, it puts the resident at risk for attempting to get up on their own instead of receiving assistance and the resident could potentially stay hungry or continue to be in pain. During a review of the facility's policy and procedure (P&P) titled Communication - Call System revised 8/24/2024, the P&P indicated the call alert system (call light) will be placed within the resident's reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 30 of 32 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 02/07/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for two (2) of 11 sampled residents (Residents 15 and 23) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/ or foot of the bed) wires for Residents 15 and 23 were not exposed (occur when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Facility failed to ensure the trash cans were not overflowing for Rooms A, B and C. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for serious illness and/ or injury. Findings: 1.During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] with diagnosis which included muscle weakness, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), history of falling. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 12/2/2024, the MDS indicated Resident 23 cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions) During observation on 2/4/2025 at 11:07 AM at Resident 23's room, Resident 23's bed control wires were exposed. During a concurrent observation and interview on 2/7/2025 at 12:05 PM with the Director of Nursing (DON), the DON stated Resident 23's bed control wire was exposed green, yellow, blue and red wire were showing. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnosis which included lack of coordination, history of falling and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15 cognitive skills for daily decision making was moderately impaired. During observation on 2/4/2025 at 2:30 PM at Resident 15's room, Resident 15's bed control were exposed. During a concurrent observation and interview on 2/7/2025 at 12PM with the DON, the DON stated Resident 15's bed control wires were exposed and the yellow, brown, red and orange wires were showing. 2.a During observation on 2/4/2025 at 11:06 AM at Room A with the certified nursing assistant 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 31 of 32 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 02/07/2025 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 (CNA 4), CNA 4 stated the trash can was open and filled with plastic and used Personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). During a concurrent interview and record review of the facility's Policy and Procedures (P&P) on 2/7/2025 at 1:23 PM with the Administrator (ADM), P&P titled Room and Environment date revised 1/1/2012. ADM stated P&P indicated Purpose to provide resident with a safe clean, comfortable and home like environment. ADM also stated all trashcans were supposed to be closed all the time. ADM also stated exposed bed control wires was not safe for residents, can cause fire, shocks and accident. 2.b During a concurrent observation and interview on 2/5/2025 at 2:56 PM with Infection Preventionist (IP) in Room B, Room B's trash can was observed to be overflowing with trash and discarded PPE. IP stated trash cans should not be overflowing and need to be sealed or covered for bacteria to not come out of the trash can. During a concurrent observation and interview on 2/6/2025 at 11:15 AM with Licensed Vocational Nurse 2 (LVN 2) in Room C, Room C's trash can was observed to be overflowing with trash and discarded PPE. LVN 2 stated when the trash is overflowing, there is no more room for anyone else to discard their trash and it should not be like that due to infection control. 2.c During an observation on 2/5/2025 at 11:40 AM in Room C, Room C's trash can was observed to be overflowing with trash and PPE. During an interview on 2/7/2025 at 1:49 PM with the DON, the DON stated trash should not be overflowing from the trash cans in residents' rooms due to being an infection control issue. During a review of the facility's P&P titled, Waste Management, revised 4/21/2022, the P&P indicated, Dispose of non-regulated waste in appropriate, non-combustible waste containers, and When waste bags are ¾ full, close bag and remove from area. Dispose bag into large, covered waste bin or cart in soiled utility room. During a review of the facility's P&P titled, Infection Control - Policies & Procedures, revised 1/1/2012, the P&P indicated, The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission(spread) of diseases and infections. The P&P further indicated an objective including, Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the general public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 32 of 32