Inspection·April 15, 2025

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 a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent) for one of two sampled residents (Resident 1) when Resident 2 touched Resident 1's buttocks and exposed Resident 2's private parts in front of Resident 1 on 4/12/2025 at around 6:50 AM. This deficient practice violated Resident 1's rights to befree from abuse 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 indicated the resident was admitted to the facility on [DATE], with diagnoses that included injury of unspecified body region (means that there is an injury, but the exact area of the body affected is not identified ) open wound right knee, sequela (resulting from prior injury), anxiety disorder (a type of mental health condition that can cause excessive worry, restlessness, difficulty concentrating, sleep disturbances, and muscle tension), effusion right ankle (the result of excess fluids gathering in the soft tissues surrounding the joint). During a review of Resident 1's History and Physical (H&P) dated 4/13/2025 indicated Resident 1 has the capacity to understand and make decisions. During a review of the Resident 1's Progress Note dated 4/12/2025 at 12:01 PM, indicated, that around 8:25 AM the Director of Nursing (DON) called asking about the sexual abuse by Resident 2 to Resident 1 that happened on 4/12/2025 at 6:50 AM. The progress notes indicated according to the Case Manager (CM), Resident 1 emailed CM (did not specify when) and claimed that Resident 2 touched Resident 1 inappropriately on the buttocks and showed Resident 2's private parts in front of Resident 1. The progress notes indicated the night shift Charge Nurse (CN) stated resident was in station 1 waiting for Resident 1's morning medication when male resident (Resident 1) passed by and touched Resident 1 inappropriately and showed his private parts to Resident 1. The progress notes indicated Certified Assistant Nurse (CNA1) was present at the time of the sexual abuse incident and told Resident 2 that what Resident 2 did was not allowed. The progress notes also indicated, Resident 2 then turned around while in his wheelchair and pulled-down Resident 1's pants and underwear to show Resident 2's private part to Resident 1 and CNA 1. The progress notes indicated, on 4/12/2025 at around 9:15 AM RN Sup 1 left a voicemail at the local PD, at 9:17 AM called SSA left message and at 9:19 AM called Ombudsman left message. (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 7 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 04/15/2025 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)