Inspection·July 16, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) Conference Record, dated 7/2/2025, the IDT record indicated Resident 1 was seen by staff being attacked by the resident's roommate (Resident 2). The IDT also indicated when charge nurse arrived both residents (Resident 1 and 2) were on the floor and Resident 2 was attempting to continue to hit/scratch/slap Resident 1. The IDT also indicated upon assessment Resident 1 was noted with scratch marks on the left arm, left cheek, left side of the forehead, and right anterior aspect of the ankle. During a record review of Resident 1's Physician Order Summary Report, dated 7/3/2025, the orders indicated as follows:- Cleanse left cheek scratch with normal saline (NS, mixture of salt and water used to replenish fluid and electrolyte), pat dry, apply triple antibiotic (used to reduce the risk of infections following minor skin injuries) and leave open to air every day shift for 30 days.- Cleanse left forearm scratch with normal saline, pat dry, apply triple antibiotic and leave open to air every day shift for 30 days.- Cleanse right heel abrasion with normal saline, pat dry, apply triple antibiotic and leave open to air every day shift for 30 days. 2. During a record review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with the diagnoses including but not limited to metabolic encephalopathy, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and personal history of other mental and behavioral disorders. During a record review of Resident 2's Physician Order Summary Report, dated 3/3/2025, the order indicated Risperidone (an antipsychotic [drugs that work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking] medication that alters the effects of chemicals in the brain) 0.5 milligrams (mg, unit of measurement): Give one tablet by mouth one time a day for Schizophrenia manifested by rapid mood cycling as evidence by sudden shifts in mood from pleasant to extreme anger as evidenced by yelling/screaming at others. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort, helper lifts or holds trunk or limbs but provides less than half the effort) for sitting to lying, sitting to standing, and walking ten feet. The MDS also indicated Resident 2 had daily verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others) directed toward others. During a record review of Resident 2's SBAR, dated 7/1/2025, the SBAR indicated Resident 2 had behavioral symptoms. The SBAR indicated at approximately at 4 AM staff reported Resident 2 was hitting Resident 1. The SBAR indicated LVN 1 arrived in Residents 1 and 2' room with both residents sitting on the floor and Resident 2 was attempting to hit/slap/scratch Resident 1. During a record review of Resident 2's care plan, dated 7/1/2025, the care plan indicated Resident 2 had a physical altercation with roommate Resident 1, at risk for injury to self or others, and at risk for repeat altercation with other residents. During a record review of the facility's final investigation report, dated 7/3/2025, the report indicated at approximately 4 AM (date not indicated), Resident 1 was seen by staff attacking Resident 2 in their room. During an observation on 7/16/2025 at 11:10 AM with Resident 1, Resident 1 was sitting in her wheelchair with scratch marks noted on the left arm. During an interview on 7/16/2025 at 11:24 AM with the Administrator (ADM), ADM stated there was a physical altercation between Resident 1 and Resident 2. ADM stated Resident 1 had scratches from the physical altercation and Resident 2 was the aggressor. During an interview on 7/16/2025 at 12:30 PM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated on 7/1/2025 from 3:30 AM to 4 AM Room A's (Resident 1 and 2's room) lights were on, the door was closed, and CNA 2 heard a big thump. CNA 2 stated she went to Room A and saw Resident 1 was on the while Resident 2 was in front of, on top of, and (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 07/16/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hitting Resident 1. CNA 2 stated Resident 2 was hitting Resident 1 while Resident 1 was putting her hands up and trying to protect herself. CNA 2 stated Resident 1 had scratches on one of her arms from Resident 2. During an interview and record review on 7/16/2025 at 2:10 PM with LVN 2, LVN 2 stated Resident 2's mood changes. LVN 2 stated Resident 2 would scream, yell and if close by Resident 2 she could grab you when she was in a bad mood. LVN 2 stated Resident 1 did not have behavior problems. During a concurrent record review and interview on 7/16/2025 at 2:24 PM with LVN 2 the facility's policy & procedure (P&P) titled, Abuse Prevention Program, revised December 2016 was reviewed. The policy indicated the facility's residents have the right to be free from abuse which includes physical abuse. LVN 2 stated the facility's resident has the right to be free from abuse. LVN 2 stated when a resident hits another resident that is not being free from abuse. LVN 2 stated Resident 1 was physically abused by Resident 2. Event ID: Facility ID: 555825 If continuation sheet Page 3 of 3