Health inspection·February 13, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) on 2/11/2026 in the facility's hallway. On 2/11/2026, Visitor (Visitor 1) witnessed Resident 2's hand was inside Resident 1's pants. This failure can result in Resident 1 and 2 experiencing emotional trauma (response to deeply distressing or disturbing events) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event).Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and hypertension (high blood pressure). The admission Record indicated Resident 1 was not self- responsible and the party responsible is Resident 1's Representative 1 (RR1). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making were severely impaired. The MDS indicated Resident 1 requires partial moderate assistance (the helper does less than half the effort) for sit to stand (the ability to a standing position from sitting), walk 10 feet (ft.-unit of measurement) once standing the ability to walk at least 10 ft, in a room, corridor or similar space once standing. The MDS also indicated Resident 1 required partial moderate assistance to wheel 50 ft. with two turns using a wheelchair. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, tool used by health care professionals when communicating about critical changes in a resident's status), dated 2/11/2026 at 3PM, the SBAR indicated Resident 1 was at risk for emotional distress related to alleged inappropriate touching. The SBAR also indicated the charge nurse received a report from a witness (Visitor 1) that Resident 1 was being touched inappropriately by Resident 2 while sitting in their wheelchair in the hallway. During a review of Resident 1's Change in Condition Evaluation dated 2/11/2026 at 2:41 PM, the change in condition evaluation indicated Resident 1 was at risk for emotional distress related to alleged inappropriate touching. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included muscle weakness, gait mobility, dysphagia (difficulty swallowing). The admission Record indicated Resident 2 was not self- responsible and the party responsible is Resident Representative 2 (RR2). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 requires partial moderate assistance on sit to stand, walk 10 ft once standing. During a review of Resident 2's SBAR dated 2/11/2026 at 3PM, the SBAR indicated there was an allegation of inappropriate sexual behavior towards Resident 1 as manifested by inappropriate touching. During a review of Resident 2's Change in (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055056 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 02/13/2026 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)