Health inspection·November 5, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm 3. Systolic blood pressure (the pressure in your arteries when your heart beats and pumps blood out) drop less than 20 millimeters of mercury (mmHg- unit of measurement used to measure blood pressure) between lying and standing 4. 1-2 present predisposing diseases (chronic conditions that can increase the risk of falling) Residents Affected - Few 5. Taking 3–4 medications (or medication classes) 6. Balance problem with walking 7. Decreased muscular coordination The Fall Risk Evaluation also indicated if the fall risk score is 10 or greater, the resident should be considered high risk for potential falls and [fall] prevention protocol initiated immediately and documented in the care plan. During an interview of 11/5/2024 at 2:29 PM with the Director of Rehab (DOR), DOR stated Resident 1 is a fall risk and should have supervision with walking due to her impaired cognitive skills and impaired ability to determine unsafe situations when ambulating, including environmental factors (examples lighting, flooring, obstacles in footpath). During an interview on 11/5/2024 at 3:30 PM with Minimum Data Set Nurse (MDSN), MDSN stated Resident 1 is confused, receiving physical therapy and needs supervision assistance when walking because of her unsteady gait (a person ' s manner of walking). MDS also stated Resident 1 should not be walking alone. During an interview on 11/5/2024 at 3:53 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 1 had unsteadiness when walking and holds the wall side rails for support. LVN 4 stated Resident 1 needs verbal and/or physical prompting with direction because she does not have full cognition in determining where she needs to go. LVN 4 also stated she needs supervision when transferring (how resident moves to and from bed, chair, wheelchair, standing position). During a concurrent interview and record review on 11/5/2024 at 4:46 PM with Director of Nursing (DON), Resident 1 ' s Risk for Falls care plan, dated 9/19/2024, was reviewed. DON stated the care plan did not address any fall prevention interventions specific to Resident 1 ' s identified fall risk factors including Resident 1 ' s cognition impairment, confusion, balance problem and unsteady gait and should have per the facility policy. DON stated Resident 1 ' s current fall risk care plan mainly addresses when a fall occurs and is missing a lot. DON stated it is important for Resident 1 to have a resident-centered care plan for falls to ensure there are specific interventions in place to direct staff and to prevent falls and/or major injuries from a fall. During a review of the facility ' s Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated fall risk factors included cognitive impairment, lower extremity weakness, medication side effects, orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position), functional impairments, incontinence balance and gait disorders. The P&P also indicated staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555825 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 555825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marino Healthcare Center 6812 N. Oak Avenue 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 0656 of falls. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the care plan indicated: Residents Affected - Few 1. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The comprehensive, person-centered care plan includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, 4. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 5. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555825 If continuation sheet Page 3 of 3