Health inspection·September 15, 2025

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitive skills for daily decision making. The MDS indicated Resident 3 required substantial/maximal assistance with eating, oral and personal hygiene, showering/bathing and dependent with toileting hygiene. The MDS also indicated Resident 3 was receiving an antibiotic in the facility. During a review of Resident 3's MARs dated 7/1/2025 through 7/31/2025 and 8/1/2025 through 8/31/2025, the MARs indicated Resident 3 was administered ciprofloxacin HCl 500 mg 1 tablet every day from 7/25/2025 through 8/12/2025 for bacteremia. During an interview on 9/15/2025 at 10:46 AM with the Infection Preventionist (IP), the IP stated the facility policy, an ATO should be done within 48 to 72 hours of starting the antibiotic. The IP states an ATO includes reviewing culture (a test to identify whether you have a bacterial infection) results, lab results and reporting to the physician and documenting if the antibiotic is continued or discontinued. During a concurrent interview and record review on 9/15/2025 at 1:37 PM with the IP, the facility's Infection Surveillance Monthly Report, dated 8/2025, indicated:a. Resident 1 had a clostridium difficile infection and treatment of metronidazole oral tablet 500 mg, ordered on 8/28/2025.b. Resident 3 with a bacteremia infection and treatment of ciprofloxacin 500 mg, ordered on 7/25/2025.The IP stated per facility protocol, Resident 1 would need an ATO done for metronidazole by 8/30/2025 and Resident 3 would need an ATO done for the ciprofloxacin by 7/28/2025. During the same concurrent interview and record review on 9/15/2025 at 1:37 PM with the IP, Resident 1 and Resident 3's electronic medical charts were reviewed. The medical charts for Residents 1 and 3 failed to indicate an ATO was completed for Resident 1's metronidazole by 8/30/2025 and an ATO for Resident 3's ciprofloxacin by 7/28/2025. The IP stated Resident 1 and Resident 3's ATOs should have been completed within the 48 to 72-hour window but were not done. The IP stated an ATO is time taken for licensed nurses to stop and check the residents for any adverse effects (an undesired harmful effect resulting from a medication or other intervention) from the antibiotics, justify continued use of the antibiotics and help prevent antibiotic resistance in the residents. The IP also stated ATO's need to be done because [most] residents are elderly and/or over the age of 65 and are vulnerable to becoming resistant to antibiotics because of frequent antibiotic prescriptions. During an interview on 9/15/2025 at 2:14 PM with the Registered Nurse Supervisor (RNS), the RNS stated ATO's are done 3 days after the initiation of antibiotics and any licensed nurse can complete the ATO. The RNS also stated that ATOs are important to assess if the resident needs the antibiotic and prevent antibiotic resistance due to unnecessary use. RNS stated if residents become resistant to antibiotics, it will limit the available antibiotics that can be used to treat their infections. During an interview on 9/15/2025 at 2:55 PM with the Director of Nursing (DON), the DON stated Resident 1 did not have an ATO completed within the 48 to 72 hours after starting metronidazole in the facility and it should have been done. The DON also stated Resident 3 did not have an ATO completed within the 48 to 72 hours after starting ciprofloxacin in the facility and it should have been done. The DON stated it is important to ensure the ATOs are completed to prevent resistance from inappropriate antibiotic use, causing multidrug-resistant organisms (MDROsbacteria or other microorganisms that have become resistant to multiple types of antibiotics) in the residents. During a review the facility's policy and procedure (P&P) titled Antibiotic Time - Out (ATO) Policy, revised 9/14/2017, the P&P indicated the need for antibiotics will be reassessed when clinical and laboratory data become available at which time an ATO will be considered and discussed with the physician. The P&P also indicated an ATO is meant to prompt the physician to revisit the need for the antibiotic 48 to 72 hours after starting the antibiotic and the facility licensed nurse (IP, DON or charge nurse) will contact the prescribing physician 48 to 72 hours after initiation of an antibiotic. During a review of the facility's P&P titled Antibiotic Stewardship, revised 5/20/2021, the P&P indicated the purpose of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055056 If continuation sheet Page 2 of 3 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 09/15/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete policy was to optimize the use of antibiotics by improving prescribing practices and reduce inappropriate antibiotic use. The P&P indicated antibiotic time-outs (ATO) is a review process for all antibiotics prescribed in the facility, and will be utilized when appropriate and prompts clinicians to reassess the ongoing need for an antibiotic after culture results are available. The P&P also indicated the facility will provide education on antibiotic stewardship to prescribing medical providers, nursing staff, other staff (as appropriate) and the IP will review antibiotic use protocols, antibiotic use and share the information with licensed nursing staff as needed. Event ID: Facility ID: 055056 If continuation sheet Page 3 of 3