Inspection·February 19, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated presence of mood symptoms such as little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired or having little energy, and poor appetite or overeating. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 received antipsychotic medication (any drug that affects brain activities associated with mental processes and behavior) on a routine basis. During a review of Resident 1's Order Summary Report dated 2/19/2025, timed 3:23 PM, indicated an order of Risperdal oral tablet 1 milligram, give 1 tablet by mouth two times a day for schizophrenia, with order date of 2/17/2025, and start date of 2/18/2025. During an observation on 2/19/2025 at 12:48 PM with Resident 1, in the activity room, Resident 1 is sitting in a chair, Resident 1 is staring at the floor, Resident faced the wall when approached, and Resident 1 refused to be interviewed. During an interview on 2/19/2025 at 12:50 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated she witnessed Resident 1 punched another resident for the first time on 2/5/2025. During an interview on 2/19/2025 at 3:06 PM with CNA 2, CNA 2 stated Resident 1 sometimes has a different mood wherein Resident 1 is hard to approach and Resident 1 just want to be left alone. During a concurrent record review and interview on 2/19/2025 at 3:12 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's active orders as of 2/19/2025 were reviewed. LVN 1 stated Risperdal for schizophrenia that was ordered on 2/17/2025 is incomplete because there is no specific targeted behavior indicated in the physician's order such as sudden striking or hitting another resident. LVN 1 stated including specific target behavior for the use of Risperdal is important to know what behaviors to monitor and to know what the medication is for. LVN 1 stated Resident 1 has no order for monitoring of specific behavior for the use of Risperdal and no order to monitor adverse reaction of Risperdal. During a concurrent record review and interview on 2/19/2025 at 3:38 PM with Registered Nurse (RN) 1, Resident 1's active orders as of 2/19/2025 were reviewed. RN 1 stated Resident 1's Risperdal order on 2/17/2025 did not and should have a specific behavior such as sudden striking or hitting another resident to be monitored for its use. RN 1 stated it was important to include the specific target behavior so the licensed nurses would know what the Risperdal is for. RN 1 stated Resident 1 did not have and should have an order to monitor adverse reaction to Risperdal. RN 1 stated that antipsychotic medication needs monitoring of specific target behavior so the facility would know if the medication was effective to manage the behavior or not. RN 1 stated specific behavior manifestation such as hitting another resident or physically aggressive behavior should have been in Resident 1's order for Risperdal, and an order of behavior monitoring that to be documented and tallied by the end of the month should be active to have validation for the effectiveness or the need of medication adjustment. During a concurrent record review and interview on 2/19/2025 at 4 PM with Interim Director of Nursing (DON), Resident 1's active orders as of 2/19/2025 were reviewed. The Interim DON verified Resident 1's has an order of Risperdal for schizophrenia, she added it was an incomplete order since there (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 02/19/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is no specific target behavior for the use of Risperdal. The Interim DON also stated monitoring of specific behavior for the use of Risperdal and monitoring of adverse reaction was not ordered for Resident 1. The Interim DON stated Risperdal order with a specific target behavior was necessary, so the staff know what the medication is for. The Interim DON stated that psychotropic drugs need monitoring of specific target behavior so the facility would know if the behavioral management was effective or not. The Interim DON stated Resident 1 has a behavior of being physically aggressive to another resident. The Interim DON verified that this behavior was not indicated in Resident 1's Risperdal order. During a review of the Facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated July 2022, indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. It also indicated consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Residents receiving psychotropic medications are monitored for adverse consequences (negative outcomes or effects). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555825 If continuation sheet Page 3 of 3