Health inspection·January 8, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs, and restlessness while in bed. The CP indicated interventions included the following:Anticipate and meet the resident's needs.Follow facility fall protocol.May put bed to the lowest position every shift for safety and history of fall related to restlessness. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) summary for providers, dated 12/31/2025 at 2:11 AM, entered by Registered Nurse 1 (RN 1), it indicated Resident 1 was observed to be restless and grimacing (a facial expression in which your mouth and face are twisted in a way that shows disgust, disapproval, or pain). During a review of Resident 1's Transfer to Hospital Summary dated 12/31/2025, timed 6:08 AM, entered by RN 1, it indicated Resident 1 was found lying on the floor between the nightstand and the bed with the resident's face down. During a review of Resident 1's Change of Condition (COC) evaluation, dated 12/31/2025, timed 7:27 AM, entered by Licensed Vocational Nurse 1 (LVN 1), the COC evaluation indicated Resident 1 had a fall. The COC evaluation indicated Resident 1 with new COC of restlessness and constant moving in bed around 2 AM. The COC evaluation indicated at 5:30 AM, Resident 1 was found on the floor on the right side of the bed. The COC evaluation also indicated Resident 1 obtained a small abrasion measuring 2 cm on the left forehead. During a review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals) Progress notes, dated 1/2/2026, timed at 12:51 PM, it indicated Resident 1 had a fall on 12/31/2025. The IDT Progress notes indicated prior to the incident, Resident 1 was observed making moaning noises and exhibiting constant movement in bed despite repositioning and distraction attempts for comfort. The IDT Progress notes indicated that Resident 1 had been restless throughout the night, with constant body movement. The IDT Progress notes indicated a root cause for Resident 1's fall was most likely due to severe cognitive impairment, restlessness, and significant physical limitations. The IDT progress notes also indicated on the night of the fall, Resident 1 exhibited agitation, restlessness, and constant movement During an interview on 1/6/2026 at 12:20 PM with RN 1, RN 1 stated she was assigned to Resident 1 on 12/31/2026 when Resident 1 had a fall. RN 1 stated on that night, Resident 1 was restless, screaming, and constantly moving in bed. RN 1 stated at around 5:30 AM, CNA 1 called her to Resident 1's room where they observed Resident 1 on the floor, face down, on the right side of the bed, between the bed and the nightstand. During an interview on 1/6/2026 at 2:17 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 is able to move while in bed, Resident 1 does not use the call light, and is unable to verbalize needs. LVN 1 stated Resident 1 did not have a bed alarm and should have an order of bed alarm to alert staff when Resident 1 is no longer in a safe position to prevent the resident from falling from the bed. LVN 1 stated bed alarm is usually placed in the middle of the bed, and it will alarm when it detects weight change when resident lifts off the bed. During an interview on 1/6/2026 at 4:05 PM with CNA 2, CNA 2 stated he is familiar with Resident 1. CNA 2 stated Resident 1 is usually restless and does not sleep in the evening like other residents. CNA 2 stated Resident 1 usually move around while in bed. During a concurrent interview on 1/7/2026 at 8:10 AM with RN 1, and record review of Resident 1's medical records dated from 11/18/2025 to 1/7/2026 were reviewed RN 1 stated that on 12/31/2025, Resident 1 has no sedative order. RN 1 stated Resident 1 is usually awake, with moaning and screaming behavior at night. RN 1 stated that Resident 1 has care plan for CAD revised on 11/18/2025 with intervention to monitor/document the resident's sleeping pattern, to inform physician of any insomnia or anxiety, and to give sedatives as ordered. RN 1 stated there was no documented evidence that Resident 1's sleep pattern has been monitored. RN 1 stated there is no sedatives order, and the CP was not resident centered. RN 1 stated (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 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Healthcare & Wellness Centre, LP 126 N. San Gabriel Blvd. San Gabriel, CA 91775 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete if Resident 1's sleep pattern/anxiety has been monitored and documented, Resident 1's Physician could have ordered a medication to relieve Resident 1's anxiety, and inability to sleep which will help prevent Resident 1 to move around in bed and could have prevented the fall. RN 1 also added Resident 1 could have benefited from a bed alarm to alert staff that resident is no longer in a safe spot so the staff can intervene right away and prevent Resident 1 from falling. During a concurrent interview on 1/7/2026 at 8:30 AM with LVN 2 and record review of medical records, LVN 2 stated monitoring and documenting sleep pattern should have been ordered if it was in Resident 1's care plan to reflect in the medication administration record, where in licensed nurses would be documenting residents' hours of sleep. LVN 2 stated a bed alarm could have prevented Resident 1's fall if it was added in the plan of care and provided to the resident. During a telephone interview on 1/8/2026 at 9:20 AM with CNA 1, CNA 1 stated that on 12/31/2025, around 1 AM, Resident 1 has been more restless than usual. CNA 1 stated that Resident 1 squirms (twist the body from side to side, especially as a result of nervousness or discomfort) in bed and being repositioned frequently. During an interview on 2/8/2026 at 10:53 AM with Assistant Director of Nursing (ADON), ADON stated Resident 1's sleeping pattern was not monitored, and there was no documented evidence of Resident 1's sleep pattern. ADON stated since it is part of Resident 1's CP, it should have been ordered to reflect in Resident 1's MAR. During an interview on 12/8/2026 at 12:39 PM with ADON, she stated Resident 1 could have benefited the use of bed alarm to alert staff when the pressure was off, it will make the staff know that the resident is no longer in a good position in bed. ADON stated that when a resident does not get enough sleep at night place the resident to be restless that is why Resident 1 does a lot of moving around the bed. During a concurrent interview and record review on 2/8/2025 at 4 PM with the Director of Nursing (DON), Resident 1's medical records dated from 3/25/2025 to 12/31/2025 were reviewed. The DON stated Resident 1 has been at risk of falling because of cognitive problems, blindness and contractures. The DON stated Resident 1 had a fall on 3/25/2025 and a care plan was initiated on 4/1/2025 that Resident 1 is risk for falls related to confusion, balance problems, poor communication/comprehension, unaware of safety needs and restlessness while in bed. The DON verified that the CP did not indicate an intervention to address Resident 1's restlessness while in bed and the intervention to follow facility fall protocol was general and not resident- specific. The DON stated, Resident 1 had a CP for CAD that was revised on 11/18/2025 with intervention to monitor and document sleep pattern, and the DON verified the intervention was not implemented or was not done. During a review of facility's P&P titled, Person-Centered care Planning, revised on 4/24/2025, it indicated interventions are actions, treatments, procedures, or activities designed to meet an objective. It also indicated Person-centered care plan means making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in nursing facility. During a review of facility's Policy and Procedure (P&P) titled, Fall Management program, revised in 8/28/2025, the policy indicated the facility will implement an interdisciplinary fall prevention program that includes risk screening, individualized care planning, and targeted interventions. During a review of facility's P&P titled, Fall Management program, revised in 8/28/2025, the P&P indicated licensed nurse will develop a care plan according to the identified risk factors. Event ID: Facility ID: 055056 If continuation sheet Page 3 of 3