Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Inadequate supervision during toileting and improper placement of fall alarm transmitters. A resident with dementia, impaired mobility, and high fall risk was left alone on the toilet and was later found on the floor outside the bathroom door. Two other residents with high fall risk had motion sensor transmitters placed incorrectly in their rooms; staff observed the devices were not facing the residents, and both an LVN and CNA stated the transmitters had to face the resident for the alarm to detect motion and alert staff.
Failure to Follow Oxygen Administration Requirements: The facility failed to post required "Oxygen in Use - No Smoking" signage outside the rooms of two residents receiving O2 via NC, including one resident with COPD and heart failure and another resident with confusion and impaired decision-making. The facility also failed to change another resident's NC and O2 humidifier as required by policy while the resident continued to receive oxygen therapy.
Failure to Follow EBP and Disinfect Shared Equipment: Staff did not consistently wear gowns and gloves during high-contact care for two residents on EBP, including G-tube care, Foley catheter care, transfers, and linen changes. An LVN also used shared BP equipment on a resident without disinfecting it before or after use. The DON and staff acknowledged the PPE and disinfection expectations, and facility policy required gown/glove use for EBP and cleaning of multiple-resident equipment after each use.
A resident with COPD and heart failure was receiving 5 LPM O2 via NC for SOB, but the facility did not develop and implement a baseline care plan within 48 hours of admission. The DON stated the baseline care plan was important for staff to provide appropriate care and interventions, yet the completed plan did not include a goal or interventions for the resident's O2 therapy.
Kitchen Pest Control and Cleaning Deficiency: A kitchen tour found unidentified debris and a dead insect behind an oven in a baking area where freshly baked cookies were nearby. The DSM stated the area needed to be cleaned because food debris or dirt could attract pests, and the ADM stated all kitchen areas needed to be clean. The facility’s cleaning schedule called for daily sweeping under equipment, counters, and racks, with heavier cleaning under equipment, walls, floors, and major equipment on a weekly basis.
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.
Inadequate supervision during toileting and improper placement of fall alarm transmitters
Penalty
Summary
The facility failed to ensure adequate supervision for a resident at high risk for falls when the resident was left alone on the toilet. The resident had diagnoses including dementia, generalized muscle weakness, and abnormal gait and mobility. The MDS showed severely impaired cognition and the resident required substantial to maximal assistance for toileting hygiene and bathing, with partial to moderate assistance for toilet transfers. The Morse Fall Scale identified the resident as high risk for falling and noted the resident overestimated or forgot limits related to going to the bathroom alone. On 6/15/2026 at 5:18 AM, the resident was found sitting on the floor with legs straight out and leaning on the right elbow. A CNA stated the resident had been assisted to the bathroom and was left momentarily on the toilet while the CNA checked on another resident next door. When the CNA returned two to three minutes later, the resident was sitting on the floor outside the bathroom door. The DON stated the resident was considered a high fall risk even before the fall because of dementia and that the CNA was not supposed to leave the resident alone in the bathroom because anything such as a fall could occur. The facility's fall prevention policy stated staff would monitor at-risk residents closely when using the bathroom, and the safety and supervision policy stated resident supervision was a core component of safety. The facility also failed to ensure proper placement of motion sensor alarm transmitters for two residents at high risk for falls. One resident had diagnoses including age-related osteoporosis and muscle weakness, with the MFS indicating high fall risk and the care plan and physician order directing a motion sensor transmitter in the room and checking its proper function and placement. During observation, the transmitter was on top of a shelf in front of the bed and was not facing the resident. An LVN stated it needed to be positioned facing the resident for the sensor to detect motion. Another resident had diagnoses including age-related osteoporosis and a history of falling, with the MFS indicating high fall risk and the care plan and physician orders directing battery function and proper placement checks for the motion sensor transmitter. During observation, the transmitter was not facing the resident and was facing toward the window. A CNA stated the transmitter needed to face the resident so the alarm would activate if the resident attempted to get up from bed. The DON stated the transmitter needed to be positioned facing residents for the alarm to work and that its purpose was to alert staff when residents got out of bed or out of the wheelchair without asking for assistance.
Failure to Follow Oxygen Administration Requirements
Penalty
Summary
The facility failed to ensure proper respiratory care for three sampled residents by not following its Oxygen Administration policy and physician orders. Resident 47, who had diagnoses including COPD and heart failure and was receiving oxygen at 5 LPM via nasal cannula for shortness of breath, did not have an "Oxygen in Use - No Smoking" sign posted in the sign plate holder outside the room. Resident 17, who had diagnoses including anemia and other circulatory and respiratory symptoms and was documented as confused and unable to make complex medical decisions, also did not have the required oxygen warning signage posted outside the room while receiving oxygen at 2 LPM via nasal cannula, with orders allowing titration up to 4 LPM to maintain oxygen saturation at 92%. The facility also failed to change Resident 30's nasal cannula and oxygen humidifier every Sunday as required by the Oxygen Administration policy. Resident 30 had diagnoses including anemia and heart failure, and the record review identified the ongoing oxygen-related care issue in the resident's plan of care and treatment records. The report states that the lack of visible warning signage and the use of an old nasal cannula and humidifier were identified during observation, interview, and record review.
Failure to Follow EBP and Disinfect Shared Equipment
Penalty
Summary
The facility failed to implement infection prevention and control measures for two sampled residents who were on Enhanced Barrier Precautions (EBP). One resident had diagnoses including dysphagia, a gastrostomy tube, transient ischemic attack, and cerebral infarction without residual deficits. The resident’s MDS showed severely impaired cognition and dependence on staff for personal hygiene and toileting. The resident’s care plan and physician orders indicated EBP for the presence of a G-tube, and the doorway had signage stating staff must wear gloves and gowns for high-contact care activities involving devices and medical treatments. During observations, staff provided G-tube care to this resident without wearing a gown. One LVN removed the G-tube feeding and gave water through the tube while wearing only gloves. In another observation, the LVN administered water and medications via the G-tube without a gown, and water spilled from the syringe onto the resident when the resident coughed. The LVN stated staff needed to wear gowns when performing patient care with the resident, including to prevent anything from getting on staff clothing and spreading infection. The DON stated all residents with G-tubes were under EBP and that staff should wear a gown and gloves when touching a resident’s G-tube because of possible splash back during medication administration. The facility also failed to follow EBP for another resident with a Foley catheter. The resident’s record showed diagnoses including cerebral infarction and prostate cancer, and the MDS indicated the resident usually understood verbal content and was dependent for toileting hygiene, oral hygiene, showers, and baths. During observations, a CNA entered the resident’s room where EBP signage was posted but did not wear a gown. The CNA emptied the Foley catheter, changed the resident’s clothing, assisted with repositioning and transfer using a sling and mechanical lift, and changed bed linens without wearing a gown. The CNA stated a gown was not needed for the transfer but was needed when emptying the Foley catheter, and stated proper PPE was needed to protect the resident and prevent bacteria from being passed to other residents. In a separate observation, an LVN used shared BP equipment for the resident without disinfecting it before or after use, and later stated the equipment was used for multiple residents and that it needed to be disinfected to prevent cross contamination. The facility’s policies stated that gowns and gloves were required for high-contact care under EBP and that multiple-resident use equipment must be cleaned and disinfected after each use.
Baseline Care Plan Not Completed for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for Resident 47, who was admitted and later readmitted with diagnoses including COPD and unspecified heart failure. Resident 47's record also showed an order for oxygen at 5 LPM via nasal cannula every shift for shortness of breath continuously, and the treatment administration record documented that oxygen was being administered at that rate since readmission. During observation on 6/22/2026, Resident 47 was in bed, frail, and receiving 5 LPM of oxygen via nasal cannula. During interviews and record review, the DON stated that a baseline care plan had to be created upon admission and was important for staff to provide appropriate care and interventions because the resident was on oxygen therapy. The baseline care plan later found in the record was completed on 6/22/2026 by the SW, MDSN, LED, and RD, but the DON stated it did not include a goal or interventions addressing the resident's oxygen therapy. The facility policy stated that a baseline care plan would be developed within 48 hours of a resident's admission and include the instructions needed to provide effective and person-centered care.
Kitchen Pest Control and Cleaning Deficiency
Penalty
Summary
The facility failed to ensure one of four corner areas in the kitchen was free of pests on 6/22/2026. During a kitchen tour observation and interview with the Dining Services Manager at 8:53 AM, a separate baking area inside the kitchen had unidentified debris and an insect that was not moving on the floor at the back of the oven, while trays with freshly baked cookies were placed in a cart nearby. The Dining Services Manager stated there was a dead insect behind the oven and identified it as a cricket, and stated that all areas of the kitchen needed to be cleaned because food debris or other dirt could attract pests into the kitchen. During a later interview, the Administrator stated all areas of the kitchen needed to be clean. The facility’s Dining Services Master Cleaning Schedule indicated floors were to be swept daily, including under equipment, counters, and racks, and the Policy and Procedure for Sanitation and Infection Control Cleaning Services stated the daily cleaning schedule delineates how often equipment must be cleaned and whose responsibility it is to clean each specific piece of equipment or area, with heavy cleaning such as under equipment, walls and floors, and major equipment planned on a weekly basis.
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 | ★★★★★ | 19 | 0 |
| Claremont Manor Care Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Claremont Care Center | 0.8 mi | ★★★★★ | 13 | 0 |
| Landmark Medical Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Claremont Heights Post Acute | 1.5 mi | ★★★★★ | 24 | 0 |
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