Other·January 10, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #27680 Surveyor ID #30258 Total Resident Population: 72 Total Resident Sample: 15 Highest Severity and Scope: G

F164 SS=E PERSONAL PRIVACY/CONFIDENTIALITY OF F164 RECORDS CFR(s): 483.10(h)(1)(3)(i); 483.70(i)(2) 11/22/2017 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 1 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident’s records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide privacy for one of 15 sampled residents (Residents 9) and one Randomly Selected Resident (RSR 18). Findings: a. An admission face sheet indicated Resident 9 was admitted to the facility on July 6, 2017. The resident's diagnoses included malignant pleural effusion (cancer that causes abnormal amount of fluid build up in the lungs). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 2 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated October 4, 2017, indicated Resident 9's primary language is Vietnamese. Resident 9 required extensive assistance with one person assist for activities of daily living. During an observation on October 29, 2017 at 07:20 am, Resident 9 was observed lying in bed uncovered wearing a diaper with her shirt pulled up exposing her stomach. The bed was adjacent to the window in the room which faced the street and facility entrance. Resident 9 was awake with her arms and hands elevated. The resident could not be understood due to language barrier. The DON was made aware. During an interview on March 29, 2017 at ...the director of staff development (DSD) stated curtains or blinds should always be drawn when providing care to residents. The DSD stated privacy is a resident's right. Review of the policy Resident's Rights, dated January 1, 2012, indicated State and federal laws guarantee certain basic rights to all residents of the facility. These rights include but are not limited to a resident's right to: Privacy. b. During a medication pass observation on October 28, 2017, at 8:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed as she administered the medications of Randomly Selected Resident (RSR) 18 via a gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach). LVN 1 partially closed the privacy curtain and began to pull up RSR 18's gown and administer his medications in thru his GT. RSR 18 was in bed C and was exposed to the resident in bed A and anyone walking in the hallway. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 3 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on October 28, 2017, at 10:30 a.m., LVN 1 stated she should have closed the privacy curtain completely to provide privacy. LVN 1 stated that she got nervous. The facility's policy and procedure dated March 2017, titled "Residents Rights - Quality of Life" indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. The policy indicated facility staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.

F226 SS=E DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 11/22/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 4 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to train employees on the policy and procedures of abuse. This failure had the potential for resident's to be affected and possibly suffer from abuse. Findings: On October 29, 2017 at staff 06:40 am., five facility staff were interviewed regarding abuse with the following findings: Two kitchen staff were unable to name the different types of abuse. One registered nurse (RN) and one licensed vocational nurse (LVN) did not know the reporting times for allegations or suspicion of abuse. One LVN stated there is a 72 hour window for reporting abuse. During an interview on October 29, 2017 at 8:50 a.m.the director of staff development stated staff had been in serviced regarding types of abuse and reporting times. In addition, the DSD stated all staff was given as reference card they could attach to their name tags that could be used as a reference. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 5 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. During interviews on October 28, 2017, at 6:10 p.m. and October 29, 2017, at 6:45 a.m., two certified nursing assistants (CNA) did not know what types of abuse to report, the timeframe when to report abuse, and what outside agencies to report abuse in accordance with the facility's abuse policies and procedures. The facility's policy and procedure dated November 2016, titled "Abuse - Prevention Program" indicated the facility conducts mandatory facility staff training programs during orientation, annually and as needed on: what is abuse, neglect, exploitation and misappropriation of resident property, identifying and reporting abuse without fear of reprisal, stress management and resident abuse prevention, and dementia management such as responding to aggressive behavior or catastrophic reactions.

F246 SS=D REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES CFR(s): 483.10(e)(3)

F246 11/22/2017 483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview the facility failed to accommodate resident needs for one Randomly sampled resident (RSR 16) out of 15 sampled residents. This failure resulted in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 6 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident becoming agitated and disruptive. Findings: An admission face sheet indicated RSR 16 was admitted to the facility on July 6, 2017. During initial tour on October 28, 2017 at 6:40 p.m., RSR 16 was observed moaning in bed. Registered Nurse 1 (RN 1) stated RSR 16 often displayed the same behavior when in bed. According to RN 1, RSR 16, did not speak English and required a translator. RN 1 notified a facility staff who spoke the residents dialect, however, the staff was unable to understand RSR 16. A second staff was called who then stated RSR 16 needed to be changed. After being changed RSR 16 was observed lying in bed calm with no further moaning. During an interview on October 28, 2017 at 07:00 p.m., RN 1 stated the facility had staff that could translate for RSR 16. According to RN 1 if staff was not available to translate when resident became agitated, the family would be notified.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 11/22/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 7 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment to one of 15 sampled residents (Resident 1) by failing to: 1. Assess and monitor Resident 1's skin condition and rashes. 2. Notify the physician timely of the change in Resident 1's skin condition when his rashes worsened and spread to his abdomen, trunk, bilateral arms and legs and sustained skin tears and scabs (a dry, rough protective crust that forms over a cut or wound during healing) caused by intense itching and scratching. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 8 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Implement the physician's order to administer Benadryl (medication used to relieve symptoms including rash, itching, watery eyes, itchy eyes/nose/throat, cough, runny nose, and sneezing) as needed for itching when Resident 1 complained of severe itching and was observed scratching vigorously. These failures resulted in Resident 1 suffering and experiencing discomfort and skin injuries from intense itching and scratching. Findings: A review of Resident 1's admission record (Face Sheet) indicated Resident 1 was originally admitted to the facility on July 12, 2017, and was readmitted on October 23 2017, with diagnoses that included malignant neoplasm (new growth of cancerous tissue) of prostate (a small gland that is part of the male reproductive system), secondary neoplasm of bone, and pathological fracture (broken bone caused by disease that led to weakness of the bone structure) of the right tibia (the inner and larger of the two bones between the knee and the ankle). A review of Resident 1's admission assessment, dated October 23, 2017, indicated resident had rashes with petechiae (a small red or purple spot caused by bleeding into the skin) on the chest and back upon admission. A review of the admission orders for Resident 1,dated October 23, 2017, indicated to administer Benadryl (used to treat allergies, hay fever, cold symptoms and sleeplessness) 25 milligrams (mg) two tablets (50 mg) by mouth four times a day as needed (PRN) for itching. Another physician's order dated October 24, 2017, indicated to apply FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 9 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fluocinonide cream (used to treat skin problems caused by allergies or other conditions) to Resident 1's chest and back area rash twice a day (BID) for three weeks. A review of the Resident 1's Care Plan for Skin Rash dated October 23, 2017, indicated Resident 1 had rashes to chest and back. The care plan goal indicated Resident 1's rash will clear or reassess, and Resident 1's itching will be relieved. The listed nursing interventions included to check Resident 1's skin to determine affected areas, provide medication and treatment as ordered and assess for effectiveness and side effects, trim/file nails, and bathe three times a week. During an initial tour observation of the facility with Registered Nurse (RN) 3 on October 27, 2017, at 7:02 p.m., Resident 1 was observed sitting up in bed scratching both arms, abdominal area and chest and rubbing back vigorously against the mattress. Resident 1 complained of severe itching. As Resident 1 leaned forward, stains of blood were observed on the pillowcase and bed sheet behind the resident's back. Resident 1's back was red and bleeding and had red pinpoint raised rashes and excoriated (abrading or wearing off the skin) rashes. Resident 1's chest, abdominal area, flanks, upper arms and legs were also observed with scattered red pinpoint raised rashes. In a concurrent interview, Resident 1 stated the staff would apply "lotion" which would help for a little bit, but "there was nothing else they could do about it." RN 3 then stated that she would check with the medication nurse if Resident 1 had something for the itching. During an observation on October 28, 2017, at 7:50 a.m., Resident 1 was observed in bed eating breakfast and constantly scratching his upper arms and trunk area and rubbing his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 10 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE back against the mattress. Resident 1's bilateral upper extremities were observed with red pinpoint rashes and scattered scabs. During a concurrent interview, Resident 1 complained of intense itching and stated that he has had the rashes for a few weeks and was getting "lotion" and Benadryl for it, but was not really helping. Resident 1 stated that he had not seen a dermatologist and asked Surveyor if he could see one right away because the itching was so uncomfortable. During an observation on October 28, 2017, at 9:45 a.m., Resident 1 was observed lying in bed. Resident 1 stated that he feels a little better after taking a shower, but he was still itching and scratching. Resident 1 stated that he feels very uncomfortable and sore from scratching too much. During an interview on October 28, 2017, at 9:55 a.m., Treatment Nurse (TN) 1 stated that Resident 1 was readmitted from the acute care hospital and the rashes to the chest and back started in the hospital. TN 1 stated that Resident 1 gets Benadryl for the itching PRN. When asked if she knew about Resident 1's skin bleeding from intense itching and scratching, TN 1 stated no and that no one reported it to her. According to TN 1, Resident 1 had not been seen by a dermatologist. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on October 28, 2017, at 10:54 a.m., Resident 1's Medication Record for October 2017 indicated the Benadryl was not administered PRN for itching since it was ordered by Resident 1's physician on October 23, 2017. LVN 1 stated that she did not know about Resident 1's rashes until yesterday. LVN 1 further stated that she was informed that Resident 1 complained of itching yesterday, but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 11 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she was busy with another resident and could not give the Benadryl to Resident 1 at that time. During a concurrent interview and treatment observation on October 28, 2017, at 11 a.m., Resident 1's skin was observed with generalized red pinpoint rashes, excoriated rashes, and scattered scabs all over resident's back, chest, abdomen, flank, and bilateral upper and lower extremities. TN 1 stated that Resident 1's rashes spread and looked worse today. TN 1 stated that she would notify Resident 1's physician and request for a dermatology consult. During an interview on October 28, 2017, at 3:20 p.m., Certified Nursing Assistant (CNA) 1 stated that she noticed Resident 1's skin with scattered red rashes on the stomach, sides, back, chest, and arms and told the charge nurse about it on Thursday (October 26, 2017). CNA 1 stated that Resident 1 had been itching and scratching and the charge nurse already knew about it. According to CNA 1, she would apply lotion to Resident 1's body. During an interview on October 28, 2017, at 4:58 p.m., the Director of Nursing (DON) stated that skin condition should be monitored while providing care and any changes in the skin should be reported to the licensed nurse and the licensed nurse should notify the physician promptly of the changes. However, the DON reviewed the clinical record and was unable to find documented evidence that Resident 1's skin condition was assessed and monitored and that Resident 1's physician was notified regarding the rashes spreading to other parts of the body and the skin bleeding from intense itching and scratching. Additionally, the DON was unable to find documented evidence that Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 12 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intense itching and scratching was addressed. After reviewing Resident 1's Medication Records, the DON stated that the Benadryl was only administered once on October 28, 2017 at 10:55 a.m. During an observation on October 28, 2017, at 5:20 p.m., the DON checked on Resident 1 with Surveyor 1 and Surveyor 2. Resident 1 was observed scratching his trunk and arms and rubbing his back against the mattress. The pillow on Resident 1's head was observed with spots of blood from the excoriated rashes. Resident 1 complained that he was itching too much and stated "Please do something." During an observation on October 29, 2017, at 6:30 a.m., Resident 1 was observed in bed awake, scratching his arms and abdomen and rubbing his back against the mattress. Resident 1 stated "This is terrible. I'm so sore from all the itching and scratching." Resident 1 stated that he was given Benadryl and it helped a little. The facility's policy and procedure dated January 1, 2012, titled "Skin and Wound Management" indicated facility staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. All nursing staff is responsible for the prompt reporting of any skin related conditions to the licensed nurse. The licensed nurse will notify the attending physician promptly at the first occurrence of a pressure ulcer or other skin related problems. The facility's policy and procedure dated January 1, 2012, titled "Change of Condition Notification" indicated the facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or an interested family FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 13 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE member, if known, when the resident endures a significant change in their condition caused by, but not limited to: an accident, a significant change in resident's physical, mental or psychosocial status; and/or a significant change in treatment. "Change of Condition" related to attending physician notification is defined as when the attending physician must be notified when any sudden or marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require medical assessment, coordination and consultation with the attending physician and a change in the treatment plan.

F314 SS=D TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 11/22/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 14 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure that necessary care and treatment, to prevent pressure sore development, were provided for one of two residents (Resident 2) with pressure sores in a total sample of 15 residents. Resident 2's bilateral heels were observed directly resting on a pillow. This had the potential to cause Resident 2's healed left heel pressure sore to reopen. Findings: A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility on June 27, 2016, and was readmitted on September 6, 2017, with diagnoses that included muscle weakness, difficulty walking, unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead tissue usually light colored, soft, moist and stringy] or eschar [thick, leathery, frequently brown or black, dead or devitalized tissue]) of the left heel and stage II (partial thickness loss of dermis [inner layer of the two main layers of cells that make up the skin]) pressure ulcer of sacral region. According to the Resident Admission Assessment dated September 6, 2017, the resident was admitted with a stage II pressure ulcer on the sacrococcyx (pertaining to both the sacrum and coccyx [tail bone]) and an arterial ulcer (wound caused by poor perfusion to the lower extremities) on the left heel. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated September 13, 2017, indicated Resident 2 scored a 13 on the brief mental status interview (BIMS, a score of 12 to 15 means cognitively intact), understood others and able to make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 15 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE self understood, and required extensive to total assistance with activities of daily living. The MDS indicated the resident was at risk of developing pressure ulcers and had a venous and/or arterial ulcer. A review of the Resident Care Plan for Skin Short Term Non-Pressure Ulcer dated September 6, 2017, indicated Resident 2 had an arterial ulcer on the left heel. The care plan goal indicated Resident 2's skin condition will heal within 21 days and Resident 2 will be free from further skin breakdown. The listed nursing interventions included to administer medication and treatment as ordered and monitor for effectiveness, keep affected area clean and dry, provide skin care, and off load heels. Further review of the care plan indicated Resident 2's arterial ulcer resolved on September 12, 2017. A review of the Resident Care Plan for Skin dated September 7, 2017, indicated Resident 2 was at risk for skin break/ulcer formation related to impaired mobility, being admitted with pressure ulcer, history of skin tear/ulcers, peripheral vascular disease and think fragile skin. The care plan goal indicated Resident 2's risk for skin breakdown/pressure ulcer will be minimized. The listed nursing interventions included to care and reposition with care rounds, encourage independent turning as applicable, provide pressure redistributing devices and assess for effectiveness, provide skin care frequently, elevate legs to decrease stasis/edema, and float heels as tolerated and utilize food cradle. During an initial tour observation of the facility on October 27, 2017, at 7:05 p.m., with Registered Nurse (RN) 3, Resident 2 was observed in bed awake and oriented. Resident 2's bilateral heels were observed directly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 16 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resting on a pillow. Resident 2 stated that he used to have a sore on his left heel and on his lower back. During an observation on October 28, 2017, at 7:30 a.m., Resident 2 was observed sitting up in bed, eating breakfast. Resident 2's bilateral heels were observed directly resting on a pillow. Resident 2's heels were not offloaded and there was no foot cradle in place as indicated on the resident's care plan. During an observation on October 28, 2017, at 1:15 p.m., Resident 2's skin was inspected with Treatment Nurse (TN) 1. Resident 2's sacrococcyx and bilateral heels were intact. However, Resident 2 bilateral heels were observed directly resting on the mattress. During a concurrent interview on October 28, 2017, at 1:15 p.m., TN 1 stated that Resident 2's pressure and arterial ulcers healed. TN 1 acknowledged that Resident 2's heels were directly resting on the mattress and stated that Resident 2's bilateral heels should be elevated and offloaded to prevent reoccurrence. The facility's policy and procedure dated January 1, 2012, titled "Skin and Wound Management" indicated facility staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. All nursing staff is responsible for the prompt reporting of any skin related conditions to the licensed nurse.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 11/22/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 17 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 18 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to assess and monitor the administration of oxygen as well as document its use for one of 15 sampled residents (Resident 12). This failure had the potential for the resident to receive unnecessary treatment. Findings; An admission face sheet indicated Resident 12 was admitted to the facility on September 13, 2016 and readmitted on October 2, 2017. The resident's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic progressive lung disease). A physician's order dated October 5, 2017, indicated to administer oxygen via nasal cannula at 2 liters per minute (LPM) continuously, and monitor oxygen saturation every shift. via a nasal cannula (a plastic tubing used for the administration of oxygen). In addition the physician's order indicated: may titrate to keep oxygen saturation greater than 92 percent (%). There were no parameters indicated in the physician's order for the titration of oxygen. On October 27, 2017 at 6:35 p.m., during initial tour, Resident 12 was observed sitting on his bed, in his room, putting on a nasal cannula. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 19 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The oxygen concentrator was administering 2 LPM of oxygen via the nasal cannula. Resident 12 was talkative, and did not exhibit any signs of distress or difficulty with breathing. Resident 12 was also observed with the nasal cannula on October 28, 2017 at 08:40 a.m., during a medication pass observation. Licensed Vocational Nurse 2 (LVN 2) did not assess the resident's airways or oxygen saturation nor did LVN 2 document the use, or rate of the oxygen flow. Review of the Medication Administration Record (MAR) for the month of October 2017, indicated oxygen saturations were not monitored daily, on every shift, as ordered by the physician. Several shifts on various days were left blank and did not indicate oxygen saturations or whether oxygen was being administered. In addition the MAR did not indicate whether the saturations were taken on room air or while the oxygen was being administered. During an interview on October 28, 2017 at 12:50 p.m., Licensed Vocational Nurse 2 (LVN 2) stated she was unsure if there was an order to monitor oxygen saturations for Resident 12. LVN 2 stated she did not obtain an oxygen saturations nor did she assess if the resident had a need for the oxygen. LVN 2 stated "He always has it on." During an interview on October 28, 2017, Registered Nurse 1 (RN 1) stated there should be parameters for the titration of oxygen. RN 1 stated because the resident had COPD, the amount of oxygen he can be administered is limited and should be monitored. Review of the facility's policy on Oxygen Therapy, dated April 1, 2013, indicated oxygen should be administered per physician's orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 20 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F332 FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1)

F332 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/22/2017 (f) Medication Errors. The facility must ensure that its(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that it is free of medication error rates of 5 percent (%) or greater. During the medication pass observation, there were two medication errors observed out of 27 opportunities for errors, which yielded a medication error rate of 7.4 %. Findings: a. During a medication pass observation on October 28, 2017, at 8:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed as she administered the medications of Randomly Selected Resident (RSR) 18 via gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach). LVN 1 administered a total of four different medications into RSR 18's GT including one crushed tablet of Vitamin D 1000 units. A review of a physician's order for RSR 18, dated October 9, 2017, indicated to administer two tablets of Vitamin D 1000 units each, for a total of 2000 units, via GT daily for supplement. During an interview on October 28, 2017, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 21 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10:30 a.m., LVN 1 reviewed the physician's order for Vitamin D and stated that she should have given two tablets instead of one. b. During a medication pass observation on October 28, 2017, at 9:15 a.m., LVN 1 was observed as she administered the medications of Randomly Selected Resident (RSR) 17. LVN 1 gave RSR 17 a total of 12 oral medications with a cup of water and a can of Glucerna. RSR 17 was observed swallowing all 12 medications with the water and continued drinking the can of Glucerna. A review of a physician's order for RSR 17, dated October 25, 2017, indicated to administer Diltiazem ER 360 milligrams by mouth twice a day for hypertensive heart disease with heart failure. A review of the pharmacy label for the Diltiazem indicated to take the medication on an empty stomach. During an interview on October 28, 2017, at 10:32 a.m., LVN 1 stated that RSR 17 ate breakfast between 7:30 a.m. to 8 a.m. and drank the can of Glucerna with the medication pass. The Diltiazem bubble pack label was then reviewed with LVN 1. LVN 1 acknowledged that there was a sticker on the bubble pack indicating to take the medication on an empty stomach. LVN 1 then stated that the Diltiazem should be given before breakfast. According to LVN 1, she would clarify the order with the physician. According to "https://www.mayoclinic.org/drugssupplements/diltiazem-oral-route/properuse/drg-20071775," swallow the extendedrelease tablet, extended-release capsule, or tablet whole. Do not open, crush, or chew it. It is best to take the extended-release capsule on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 22 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an empty stomach.

F458 SS=B BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii)

F458 11/22/2017 (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that 13 of 31 resident rooms (Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23) met the minimum square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. These 13 rooms with insufficient square footage could lead to possible inadequate nursing care to the residents. Findings: During an initial tour observation of the facility on October 27, 2017, between 6:45 p.m. and 8 p.m., there were 13 of 31 resident rooms (Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23) observed that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms. Ambulatory and wheelchair-bound residents in these rooms were observed able to move freely and the nursing staff had sufficient space to provide care to the residents. Other residents were bed-bound with medical equipment(s) in their rooms. During the survey from October 27, 2017 to October 29, 2017, observations and interviews with residents in the above-mentioned rooms FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 23 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated that the rooms had sufficient storage spaces, furnishings, and reasonable amount of privacy and space to care for these residents. During the group interview on October 28, 2017, at 2 p.m., 10 of 10 alert and oriented residents did not complain of any problem with their current rooms. On October 28, 2017, at 6:05 p.m., an interview was conducted with the administrator regarding the 13 resident rooms that did not meet the minimum requirement of 80 sq. ft. per resident in multiple resident rooms. The administrator submitted a room wavier for these 13 resident rooms together with a completed client accommodations analysis form (a form which shows the room measurements, floor area [square footage] and bed capacity for each room). On October 29, 2017, a review of the room waiver was conducted. The room waiver indicated that these rooms were in accordance with the needs of the residents, and would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being. The room waiver indicated the following: Rm. # Beds 5 3 7 3 9 3 11 3 15 3 16 3 17 3 18 3 19 3 20 3 21 3 22 3 Sq. Ft. 217 217 217 217 217 217 217 217 217 217 217 217 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 24 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 23 3 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 217 The minimum square footage for a 3-bedroom is 240 sq. ft. These resident rooms were below the minimum requirement which could lead to possible inadequate nursing care to the residents in these rooms.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 11/22/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 25 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain an accurate record for one of 15 sampled residents (Resident 10) by failing to accurately transcribe a treatment order to the treatment administration record. This deficient practice had the potential to cause treatment errors. Findings: A review of Resident 10's Face Sheet indicated Resident 10 was admitted to the facility on April 11, 2017, with diagnoses that included cellulitis of the right lower limb, dementia without behavioral disturbances, and generalized muscle weakness. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated October 2, 2017, indicated the resident had short and long term memory problem, was severely impaired in her cognitive skills for daily decision making, rarely/never understood others and rarely/never made self understood, and required extensive assistance with activities of daily living. The MDS indicated skin and ulcer treatments for Resident 10 included application of ointments/medications other than to feet. A review of a physician's order dated October 10, 2017, indicated to apply Fluocinonide 0.1% cream to affected area BID for four weeks for generalized dermatitis unspecified (skin inflammation). Another physician's order dated October 24, 2017, indicated to discontinue Fluocinonide and apply Clobetasol 0.05% gel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 26 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to affected area BID for four weeks. A review of the Resident Care Plan for Skin Rash dated October 10, 2017, indicated Resident 10 had a diagnosis of dermatitis unspecified. The care plan goal indicated Resident 10's rash will clear or reassess and the itching will be relieved. The listed nursing interventions included to provide medication and treatment as ordered and assess for effectiveness and side effects. The care plan approach was revised on October 24, 2017, indicating to discontinue previous treatment and change treatment to Clobetasol gel 0.05% to abdomen, chest, and back twice a day for four weeks. A review of the Treatment Administration Record (TAR) for October 2017 indicated Resident 10 received Fluocinonide 0.1% cream to chest, abdominal area, and back twice a day for dermatitis unspecified from October 10, 2017 to October 28, 2017. There was no documented evidence that the treatment order was changed from Fluocinonide cream to Clobetasol gel on October 24, 2017 per the dermatologist's order. During an interview on October 29, 2017, at 11:30 a.m., Treatment Nurse (TN) 1 stated that Resident 10's rashes on the chest, abdomen, and back were getting better after the treatment was changed from Fluocinonide cream to Clobetasol gel on October 24, 2017. TN 1 stated that she was the one who noted the physician's order and carried it out on the same day. When the TAR was reviewed with TN 1, she stated that she made a mistake in transcribing the order. TN 1 stated that she had been applying the Clobetasol gel since it was ordered on October 24, 2017, but was initialing that she was applying the Fluocinonide. TN 1 stated that she documented it incorrectly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 27 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation on October 29, 2017, at 11:32 a.m., the treatment cart was inspected with TN 1. TN 1 showed an open tube of Clobetasol 0.05% gel labeled with Resident 10's name and information. TN 1 stated that she had been applying the Clobetasol gel to Resident 10's rashes since it was ordered and just did not transcribe the order on the TAR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 28 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F517 WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 SS=C PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/22/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain the disaster manuals with emergency codes for missing person and bomb threat. This missing information may delay the staffs' emergency response time that could lead to possible harm to residents, visitors and staff. Findings: On October 27, 2017, at 7:30 a.m., the facility's Fire and Disaster Manual with an approval date of June 1, 2017 was reviewed. The manual did not include the facility's bomb threat and missing person code. During an interview on October 27, 2017, at 7:45 a.m., the Administrator reviewed the facility's Fire and Disaster Manual and was unable to find documented information about the facility's bomb threat and missing person code. According to the Administrator, he would add the information in. On October 28, 2017 and October 29, 2017, facility staff from all shifts were interviewed about the facility's emergency preparedness policies and procedures. Three staff failed to provide the code for missing person and bomb threat. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 29 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F518 TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/22/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to train staff on emergency and disaster policy and procedures. Findings: Review of the facility's disaster manual approved on June 1, 2017, indicated the following: Code for Fire: Dr Red, Code for bomb: Code Yellow, Missing person: Code Green. In addition the disaster manual indicated the earthquake/disaster plan and evacuation procedures. On October 29, 2017 at 06:30 am, five facility staff were interviewed regarding emergency preparedness. Two kitchen staff did not know the codes for fire, disaster and bomb threat. One licensed vocational nurse and one registered nurse did not know earthquake evacuation procedures. The director of staff development (DSD) was notified of the findings on October 29, 2017 at 8:50 a.m. b. During interviews on October 28, 2017, at 6 p.m. and October 29, 2017, at 6:45 a.m., two facility staff were interviewed regarding emergency preparedness. Two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 30 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055056 (X3) DATE SURVEY COMPLETED 10/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE GROVE HEALTHCARE & WELLNESS CENTRE, LP 126 N San Gabriel Blvd San Gabriel, CA 91775 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE certified nursing assistants (CNAs) did not know the facility's earthquake evacuation procedures and the bomb threat and missing person code. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z1XI11 Facility ID: CA950000057 If continuation sheet 31 of 31