Inspection·March 14, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) privacy was protected while Resident 1 was using the restroom/bathroom on 2/28/2025 in accordance with the facility's policy titled, Resident Rights. This deficient practice violated Resident 1's rights to privacy and has the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person's wellbeing and how they function) outcomes to the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/10/2025, the MDS indicated Resident 1 had moderate cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial/ maximal assistance (helper does more than half the effort) with oral, toileting, and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required supervision (helper provides cues) with eating. During a review of Resident 1's progress notes dated 2/28/2025 at 2:42 PM, the progress notes indicated the Social Worker (SW) was informed by Resident 1 that Resident 2 went into the restroom and asked Resident 1 to get out because Resident 2 is going to take a shower. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive skills for daily decision making. The MDS also indicated Resident 2 required setup assistance (helper sets up or cleans up; resident completes activity) with toileting and personal hygiene, shower, and lower body dressing and was independent (resident completes the activity by himself with no assistance from a helper) with eating, oral hygiene, upper body dressing and putting on/taking off (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 03/14/2025 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)