Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount San Antonio Gardens during CMS and state inspections, most recent first.
Two residents with dementia, gait/mobility impairments, history of falls, and high Morse Fall Scale scores had care plans that included motion sensor alarms as fall-prevention interventions. Surveyors observed that the room sensors were positioned facing each resident, but when an LVN triggered the sensors, the CNA carrying the paired wireless alarm device did not respond, no audible alarm was heard, and the CNA did not communicate being occupied. The CNA was later found in the staff lounge, and testing showed the pocket alarm did not sound until a button was manually pressed, after which the CNA stated the alarm might have turned off in the pocket, demonstrating that the facility failed to ensure the alarms were functioning and that staff responded as required.
A resident with COPD and heart failure experienced a significant change in condition, including confusion and shortness of breath. Although a CNA reported the symptoms and an LVN administered oxygen and a breathing treatment, the LVN did not immediately notify the physician as required by facility policy. Staff interviews and documentation confirmed this delay in notification.
A resident with a history of UTIs and total dependence on staff for hygiene was not provided adequate perineal care, as staff reused wipes for multiple cleaning passes instead of using a new wipe for each stroke, contrary to facility policy. This practice was observed and confirmed by staff interviews, and the resident's family expressed concern about recurrent UTIs.
A resident with severe cognitive impairment and total dependence on ADLs was found with all four quarter bed rails raised, but the facility's assessment, physician's order, and consent form each described different rail configurations, none matching the actual setup. The facility also failed to document that the risks and benefits of the bed rails were explained to the resident's representative, resulting in unclear and incomplete informed consent.
A resident with severe cognitive impairment and multiple diagnoses was found with all four quarter bed rails raised, but the facility's documentation was inconsistent. The side rail assessment, physician's order, and consent form each described different rail configurations, and staff confirmed these records did not match the actual setup or each other, resulting in unclear documentation regarding the use and consent for bed rails.
The facility failed to follow proper food storage practices by not labeling or dating food items in Kitchen 1, including spices, fruits, and frozen goods. This was observed during a survey, and staff interviews confirmed the facility's policy required labeling to prevent serving expired food, which was not followed.
A facility failed to accurately assess a resident for elopement risk, despite the resident's history of leaving the facility and attempts to do so without assistance. The resident, diagnosed with dementia, was found outdoors without staff assistance and had an ankle monitor to alert staff. Interviews with staff confirmed the resident was an elopement risk, but the assessment was incorrect, contrary to the facility's policy.
A resident with multiple diagnoses, including atrial fibrillation and hypertension, did not receive adequate care for a skin tear and edema. Despite orders for Geri sleeves to protect the skin, staff failed to apply them, and necessary skin assessments were not conducted. The resident's condition worsened, leading to concerns about neglect and inadequate treatment.
A resident's dirty laundry was improperly stored on a toilet seat by hospice staff, contrary to the facility's infection control policy. The resident, with cognitive impairments and dependent on assistance, had their laundry left inappropriately, risking contamination. Staff interviews confirmed the hospice staff's failure to follow proper procedures.
Failure to Ensure Functioning Motion Sensor Alarms and Staff Response for High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that motion sensor alarms used as fall-prevention interventions were functioning and appropriately monitored for two residents identified as high fall risk. Resident 2 was admitted with dementia, gait and mobility abnormalities, and was assessed on the MDS as dependent in ADLs with short- and long-term memory problems. A Morse Fall Scale dated 1/8/2026 showed Resident 2 was at high risk for falls, and the care plan, revised the same day, included a motion sensor alarm in the room as an intervention due to impaired balance, impaired mobility, and attempts to get out of bed unassisted. Resident 3 was admitted with a history of falling and muscle weakness, had a care plan indicating risk for recurrent falls related to impaired balance and mobility, and had an assisted fall on 12/23/2025 when attempting to walk without calling for staff. Resident 3’s MDS showed intact cognition with a need for maximal assistance, and a Morse Fall Scale dated 12/30/2025 also identified high fall risk; the care plan likewise included a motion sensor alarm. Surveyor observations and staff interviews showed that the wireless sensor alarm system was not being used as intended and was not reliably functional. CNA 2 reported having two alarms for these residents and produced two white alarm devices from a pocket. CNA 1 explained that the facility practice was for CNAs to carry a white device paired with the room sensor and to respond visually to the resident when the device sounded after motion was detected. The DON stated that CNAs needed to carry the sensor alarms at all times and that response to an activated alarm should be immediate, with CNAs expected to leave the alarm with nursing staff if they were too busy to respond. Despite these stated practices, subsequent testing of the alarms and staff response revealed failures. During observations with LVN 2, the motion sensors in both residents’ rooms were positioned on tables facing the residents in bed. When LVN 2 moved in front of Resident 2’s sensor to activate it and then waited in and outside the room, CNA 2 did not respond, and there was no audible alarm sound heard between 2:37 PM and 2:41 PM; CNA 2 also did not communicate being busy. A similar test in Resident 3’s room showed no audible alarm and no response from CNA 2. CNA 2 was later observed in the staff lounge. When CNA 2 then moved in front of both residents’ sensors, the alarm device in CNA 2’s pocket did not sound until a button was pressed, after which an audible alarm was heard; CNA 2 stated the alarm might have turned off while in the pocket. The facility’s product description for the alarms indicated they are wireless bed alarms intended to alert staff when a patient gets up so staff can assist to prevent falls, and the facility’s fall prevention policy described a program to identify fall risk and implement interventions, but the alarms for these two high-risk residents were not functioning or being monitored as required at the time of surveyor observation.
Failure to Promptly Notify Physician of Resident's Change of Condition
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to promptly notify the physician of a resident's change of condition (COC). The resident, who had chronic obstructive pulmonary disease (COPD) and systolic congestive heart failure, was admitted with severely impaired cognition and required maximal assistance with daily activities. On the morning in question, the resident was observed to be confused, less responsive, and experiencing shortness of breath with increased fatigue. The Certified Nursing Assistant (CNA) reported these symptoms to the LVN, who checked the resident's oxygen level and administered a routine breathing treatment and oxygen, but did not immediately notify the physician of the change in the resident's condition. Further observations throughout the day confirmed the resident continued to have fast, shallow breathing and remained on oxygen. Interviews with staff, including the CNA, Activities Assistant, Registered Nurse (RN), and Director of Nursing, confirmed that the resident's symptoms were not typical and constituted a significant change in condition that required immediate physician notification according to facility policy. The facility's policy and procedure also required prompt reporting of any change in condition to the physician to ensure proper treatment, which was not followed in this instance.
Inadequate Perineal Care Provided to Dependent Resident with UTI History
Penalty
Summary
A deficiency was identified when staff failed to provide adequate perineal care for a resident with a history of urinary tract infections (UTIs) and total dependence on staff for activities of daily living, including personal and toileting hygiene. The resident, who was frequently incontinent of urine and bowel, had documented episodes of E. coli and yeast present in urine cultures. During observation, a certified nursing assistant (CNA) cleaned the resident's perineal area from front to back using wipes, but reused the same wipe for multiple passes instead of using a new clean wipe for each stroke as required by facility policy. This practice was confirmed during interviews with both the CNA and a registered nurse (RN), who acknowledged that reusing wipes could lead to contamination of the perineal area. The facility's policy and procedure for perineal care specified that a new section of the washcloth or a new disposable wipe should be used for each stroke, particularly when cleaning the urethral meatus and vaginal orifice, to prevent infection. The observed deviation from this protocol was corroborated by staff interviews and was inconsistent with both facility policy and CDC guidance on UTI prevention. The resident's family member also expressed concern about the resident's recurrent UTIs, further highlighting the importance of proper perineal care in this case.
Failure to Ensure Accurate Assessment, Consent, and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed rails for a resident with severe cognitive impairment and total dependence on activities of daily living and mobility. The resident was observed with all four quarter rails raised and locked, but the facility's documentation did not align with the actual bed rail configuration in use. Specifically, the side rail assessment indicated full side rails on two sides, the physician's order called for bilateral half rails times four, and the consent form referenced quarter rails on two sides. None of these documents accurately reflected the four quarter rails that were actually in use for the resident. Additionally, the facility did not obtain informed consent that matched the physician's order or the actual bed rail setup. The consent form signed by the resident's representative described a different rail configuration than what was implemented, and there was no documented evidence that the risks and benefits of using all four quarter side rails were explained to the resident's responsible party. This created a lack of clarity regarding the intervention to which consent was given and whether the resident's representative was fully informed. Interviews with facility staff, including an LVN and the DON, confirmed these inconsistencies and acknowledged that the documentation did not accurately reflect the resident's needs or the actual intervention in place. Facility policies reviewed required that the risks and benefits of side rail use be explained and that documentation be complete and accurate, but these requirements were not met in this case.
Inaccurate Documentation of Bed Rail Use and Consent
Penalty
Summary
The facility failed to ensure accurate and consistent documentation regarding the use of bed side rails for one resident. The resident, who had diagnoses including dementia, hypertension, and dysphagia, and was assessed as having severe cognitive impairment and being dependent in activities of daily living and mobility, was observed with all four quarter rails raised on their bed. However, the side rail assessment documented in the medical record indicated the use of full side rails on two sides, which did not match the actual configuration in use. Additionally, the physician's order specified bilateral half rails times four, while the side rail consent form signed for the resident indicated quarter rails on two sides, further contributing to the inconsistency. Interviews with facility staff, including an LVN and the DON, confirmed that the documentation in the resident's record did not accurately reflect the physician's order or the actual bed rail setup. The discrepancies between the side rail assessment, the physician's order, and the consent form resulted in a lack of clarity regarding the type of side rails to be used and whether the resident's representative had consented to the correct intervention. The facility's policy required that documentation be objective, complete, and accurate, but this was not followed in the case of this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to safe and proper food storage practices as per professional standards and its own policy and procedure. During an observation and interview, it was noted that several food items in Kitchen 1 were not labeled or dated. Specifically, an unlabeled 20 oz Lawry's Salt-Free 17 Seasoning, a 16 oz Sysco Imperial Ground Nutmeg, and a 26 oz Sysco Imperial Granulated Garlic were found on the preparation counter. Additionally, an unlabeled orange and apple were stored in a fruit basket, and inside Refrigerator 10, there were unlabeled bags of frozen potato wedges and onion rings. Refrigerator 3 contained unlabeled boxes of fresh apples, oranges, lemons, onions, and two 1-gallon Sysco Ultra Premium Lime Juice containers with varying contents remaining. Interviews with the Purchasing Clerk and Cold Food Prep staff revealed that the facility's practice was to label food items with the arrival date to track expiration and prevent serving expired food, which could lead to foodborne illness. The facility's policy and procedure on labeling and dating required all foods to be wrapped, labeled, and dated according to storage guidelines, with use-by dates monitored and followed. The Food Safety Management System policy provided specific storage guidelines for various food items, but these were not adhered to, leading to the deficiency.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to accurately assess a resident for elopement risk, which could lead to inadequate treatment and care services. The resident, who was admitted with diagnoses including dementia and a history of repeated falls, had a documented history of leaving the facility. Despite this, a recent elopement risk assessment indicated the resident was not at risk. However, records showed the resident had been outdoors without assistance and had attempted to leave the facility multiple times. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the resident was considered an elopement risk due to their behavior and history. The facility's policy required elopement risk assessments for residents with certain risk factors, but the assessment for this resident was found to be incorrect. The resident's care plan and medical records indicated a need for monitoring and interventions, such as an ankle monitor to alert staff when the resident was near exit doors.
Failure to Provide Adequate Skin Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care according to the facility's policies and procedures. The resident, who was admitted with multiple diagnoses including atrial fibrillation and hypertension, had a care plan that included interventions for assessing skin integrity and applying Geri sleeves to protect against skin breakdown. However, the facility did not adequately monitor or care for the resident's skin tear and edema, leading to no improvement in the resident's condition. Observations and interviews revealed that the resident's legs were swollen and discolored, with a skin tear on the left ankle that was not healing. The resident expressed concern and disappointment over the lack of care, stating that the swelling had worsened since admission. Despite physician orders for Geri sleeves to be applied daily, the resident was not wearing them, and staff failed to carry out the order, which was crucial for protecting the resident's fragile skin. Interviews with staff, including a Quality Assurance Nurse and a Registered Nurse, confirmed that the necessary skin assessments were not conducted, and the physician's orders were not followed. The Assistant Director of Nursing acknowledged that a skin assessment should have been performed due to the worsening condition and that the Geri sleeves could have minimized further skin breakdown. The facility's policies and procedures emphasized the importance of recognizing changes in residents' conditions and providing appropriate treatment, which was not adhered to in this case.
Improper Storage of Dirty Laundry by Hospice Staff
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the improper storage of dirty laundry for a resident. During an observation, a closed bag of dirty laundry, including bed linen, was found on top of the toilet seat in the resident's restroom. This was contrary to the facility's policy, which requires all soiled laundry to be placed directly into a closed laundry hamper bag. The incident involved a resident who was admitted with diagnoses including cerebral infarction, hypertension, and atrial fibrillation, and who was moderately impaired in cognitive skills and dependent on assistance for toileting hygiene. Interviews with staff revealed that hospice staff, who were assisting with the resident's care, were responsible for leaving the bag of dirty laundry on the toilet seat. The Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IP) both confirmed that the hospice staff should have placed the dirty laundry in the designated dirty linen barrel to prevent contamination and ensure infection control. The facility's infection prevention and control program, as well as the personal laundry policy, were not adhered to in this instance, leading to a potential risk of cross-contamination and infection transmission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pomona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Place Health Services Center | 0.6 mi | ★★★★★ | 20 | 0 |
| Claremont Manor Care Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Claremont Care Center | 0.8 mi | ★★★★★ | 14 | 0 |
| Landmark Medical Center | 1.2 mi | ★★★★★ | 26 | 0 |
| Claremont Heights Post Acute | 1.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.