Inspection·January 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 one of three sampled residents (Resident 1), wore the [NAME] brace (a brace used to stabilize and treat broken bones in the upper arm) as ordered by the physician and indicated in Resident 1 ' s care plan. Residents Affected - Few This failure placed Resident 1 at risk for delayed healing and/or worsening of the right humerus fracture (a break in the upper arm bone on the right side of the body) and a decline in right arm range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension). Findings: During a review of Resident 1 ' s admission Record, the admission indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture (two or more portions of broken bone come out of proper alignment) of shaft of humerus (upper arm bone) on the right arm, pathological fracture (a break in an area of bone that has been weakened by an underlying disease) of the right humerus and dementia (decline in mental ability severe enough to interfere with daily functioning/life). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 1/24/2025, the MDS indicated Resident 1 with severely impaired cognitive skills (ability to understand and make decisions). The MDS indicated Resident 1 was dependent (helper does all effort needed to complete activity) with eating, bathing, dressing, toileting and oral hygiene. During a review of Resident 1 ' s History & Physical (H&P), dated 1/22/2025, the H&P indicated Resident 1 was unable to communicate/make decisions for self. During a review of Resident 1 ' s Order Summary Report, dated 1/30/2025, the Order Summary Report indicated Resident 1 would wear [NAME] brace to the right upper extremity at all times until cleared by MD and may be removed during sponge bathing while maintaining fracture and non-weight bearing precaution to right upper extremity (RUE) every shift. During a review of Resident 1 ' s Fracture to the Right Humerus care plan (a document that outlines the facility ' s plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), revised 1/15/2025, the care plan indicated [NAME] brace to Resident 1 ' s right upper extremity at all times until cleared by the medical doctor (MD). (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: 555825 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 01/30/2025 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)