Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Gabriel Valley Medical Ctr D/p Snf during CMS and state inspections, most recent first.
A resident with multiple medical conditions and cognitive intactness reported that an LVN caused him to hit his head on the headboard while being repositioned in bed. The resident and his responsible party informed the Nurse Manager, who did not assess the resident or notify the physician, and no related documentation was found in the medical record. Staff interviews confirmed that standard practice and facility policy require a head-to-toe assessment, neuro checks, physician notification, and documentation after a reported head injury or change in condition, but these actions were not carried out in this case.
A resident with multiple medical conditions, cognitively intact but dependent for many ADLs, reported that an LVN caused his head to hit the headboard while pulling him up in bed. The resident and his responsible party informed the nurse manager, and the LVN acknowledged the incident to the nurse manager. However, review of the chart showed no documentation by any licensed nurse of the incident, assessment, or follow-up, despite staff statements and facility policies requiring timely, factual documentation of such events in the medical record.
A resident with complex medical needs and high dependence on staff for daily care was discharged without receiving the required 30-day written notice. Facility staff communicated discharge plans verbally but did not provide written notification to the resident or family, and the facility's policy lacked the required notice provision. The responsible party and ombudsman raised concerns about the discharge process, and staff interviews confirmed the deficiency.
Two residents with severe cognitive impairment did not receive care that promoted dignity and respect. One was addressed by a term of endearment rather than by name or title by an LVN during medication administration, and another was provided incontinent care by a CNA without the privacy curtain fully drawn or the door closed, exposing the resident. Staff and facility policy confirmed the expectation to use proper names and ensure privacy during care.
Three residents at risk for or with existing pressure ulcers were found with low air loss mattresses set below the required weight-based settings, contrary to physician orders and facility policy. Nursing staff confirmed the incorrect settings and acknowledged that this could compromise pressure ulcer prevention and wound healing.
Two residents with G-tubes did not receive care in accordance with facility policy: one had medications administered while tube feeding was running, and another received multiple medications mixed together and rapidly pushed through the tube with a syringe plunger, rather than by gravity. Facility policy requires tube feedings to be paused and medications to be given separately and by gravity, but these procedures were not followed.
Surveyors observed multiple failures in infection prevention and control, including a catheter drainage bag left on the floor, staff not changing gloves or performing hand hygiene between tasks during medication administration and dressing changes, and unclean medical equipment. These lapses involved residents with significant cognitive and physical impairments and were confirmed by staff interviews and facility policy reviews.
A resident's confidential medical information, including medication list and date of birth, was left visible on an unattended computer monitor on a medication cart in the hallway. The resident had multiple diagnoses and was fully dependent on staff. Staff interviews and facility policy confirmed that monitors should be turned off or blanked when unattended to comply with HIPAA, but this procedure was not followed, resulting in a breach of confidentiality.
A resident with severe cognitive impairment and multiple health conditions was prescribed Apixaban via G-tube, with a care plan requiring monitoring for bleeding and medication effectiveness. Facility staff failed to document or perform this monitoring, as confirmed by record review and staff interview, resulting in a deficiency in care planning and implementation.
A resident who was fully dependent on staff for ADLs and had significant cognitive and physical impairments was found with long, untrimmed fingernails on both contracted hands. Staff confirmed that nail care is part of daily grooming responsibilities, and facility policy requires CNAs to provide such care as needed for hygiene and safety.
Two residents at high risk for venous thromboembolism did not receive sequential compression device (SCD) therapy as ordered by their physicians. Observations showed that SCD sleeves were either not applied or the machines were turned off while the residents were in bed, despite staff acknowledging the importance of SCD use for VTE prevention.
A nurse mixed Lactulose and Rivastigmine together with water and administered the combined medications rapidly through a G-tube to a resident with multiple diagnoses, including Alzheimer's disease and Parkinson's disease. This action was not in accordance with facility policy, which required medications to be given separately and via gentle instillation or gravity, with flushing between each medication.
A nurse mixed and administered Lactulose and Rivastigmine together via G-tube to a resident with multiple complex conditions, contrary to facility policy and accepted standards, resulting in a medication error rate of 8% during observation.
The facility did not ensure that opened refrigerated food items and unopened food items removed from their original packaging were properly labeled with required information such as used by date, opened date, and item name. This was observed during a kitchen inspection, where containers of peeled garlic and various salad dressings lacked appropriate labeling, contrary to facility policy and staff statements.
A facility failed to report a bruise on a resident's leg to the physician and next of kin in a timely manner, violating its policy on changes in resident condition. The bruise was discovered but not reported for two days, despite the resident's complex medical history and comatose state. The resident's daughter was upset upon discovering the bruise, highlighting a communication lapse.
The facility failed to provide necessary treatment and services to prevent and heal pressure injuries for three residents. One resident developed a new stage 2 pressure injury due to inadequate monitoring and documentation. Two other residents had their low air loss mattresses set incorrectly, placing them at risk for pressure injuries.
The facility failed to follow its policy for verifying G-tube placement by auscultating the epigastric area while injecting air for two residents with severe cognitive impairment. Both the LVN and RN admitted to forgetting this critical step, which is necessary to ensure proper G-tube placement and reduce the risk of complications.
The facility failed to provide necessary respiratory care services for three residents with tracheostomies by not having emergency equipment available in the activity room for accidental decannulation. The residents were observed without a respiratory therapist present and without necessary emergency equipment, contrary to the facility's policy.
The facility failed to ensure safe pharmaceutical services by not disposing of expired medication, not properly storing medications, and not keeping medication carts locked. An expired Desitin paste was found in a medication cart, a Primidone blister packet was found on the floor near a resident's doorway, and medication carts were observed unlocked and unattended.
The facility failed to label food items with names, dates opened, and expiration dates, and did not maintain clean kitchen surfaces. Additionally, personal belongings were found in the kitchen storage room, all of which could lead to food contamination.
The facility failed to properly dispose of garbage in the kitchen by not having lids on the garbage containers, contrary to the facility's policy. Multiple uncovered garbage cans were observed, and the Dietary Director acknowledged the need for fitting lids to prevent food contamination.
A facility failed to ensure a resident's indwelling catheter urine collection bag was covered by a dignity bag, exposing the urine and allowing the bag and tubing to touch the floor. This oversight was confirmed by staff and violated the facility's policy on resident privacy and dignity.
The facility failed to ensure a homelike environment for a resident by using the room to store hospital equipment, not replacing a broken window screen, and leaving a used disposable cup on the floor. The resident had severe cognitive impairment and required assistance for daily activities. The facility's policy emphasized creating a homelike atmosphere, which was not followed in this case.
The facility failed to post complete Nurse Staffing Information by not including the total and actual number of hours worked by licensed and unlicensed nursing staff per shift. This was confirmed by the Unit Secretary and the Director of Nursing, who acknowledged the lack of a compliant policy.
Failure to Assess and Notify Physician After Reported Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to meet professional standards of quality by not assessing or notifying the physician after a resident reported hitting his head on the headboard while being repositioned in bed by an LVN. The resident, who had a history of cholecystectomy, recurrent aspiration pneumonia, and coronary artery disease status post bypass, was cognitively intact but dependent for most activities of daily living. During an interview, the resident stated that the LVN hit his head sometime in November and that he informed the Nurse Manager. The Nurse Manager confirmed that the resident and his responsible party reported that the resident hit his head while being pulled up in bed, but she did not perform an assessment or notify the physician. Review of the medical record by the MDS nurse showed no documentation of any assessment or physician notification related to the reported head injury. Other nursing staff interviews described the facility’s standard practice and expectations when a resident reports hitting their head. An LVN stated that licensed nurses should assess the resident and notify the physician so appropriate tests and assessments can be ordered, and emphasized the importance of documenting assessments and tests after a resident reports being hurt. An RN stated that standard practice is to perform a head-to-toe assessment, interview the resident, check for injuries, notify the physician, and conduct neuro checks for 72 hours after a head injury, and that such an event is considered a change in condition. Facility policies on change in resident condition and charting required prompt communication of unusual signs and symptoms to the physician and responsible party, documentation of changes in condition and assessments, and at least daily nursing notes. These expectations and policies were not followed in response to the resident’s report of hitting his head.
Failure to Document Resident Head Injury Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident who reported hitting his head during care. The resident, who had a history including status post cholecystectomy, recurrent aspiration pneumonia, and coronary artery disease status post bypass, was cognitively intact and dependent for multiple ADLs, including bed mobility. During an interview in his room, the resident, using a Passy Muir Valve, stated that a licensed vocational nurse had hit his head sometime in November while pulling him up in bed, and that he had informed the nurse manager. The nurse manager later confirmed that the resident and his responsible party had reported that the resident’s head hit the headboard while the LVN was pulling him up in bed, and that the LVN also confirmed the incident occurred during care. Despite these reports, review of the resident’s medical record with the MDS nurse showed no documentation by the LVN or any licensed nurse that the resident’s head had been hit while being repositioned in bed. Staff interviews indicated that the facility’s standard practice and expectation was that any incident in which a resident was hurt or reported being hurt during care should be documented in the medical record, including a description of the incident, a head-to-toe assessment, interventions, injuries, and physician notification. The nurse manager acknowledged she did not document the incident in the resident’s medical record. This lack of documentation was inconsistent with the facility’s written policies on charting and documentation, which require factual, specific, accurate, and timely entries of clinical events and changes in condition.
Failure to Provide Written Discharge Notice and Safe Discharge Planning
Penalty
Summary
The facility failed to implement an appropriate discharge plan for a resident by not providing a written discharge notice to the resident and their family, and by not re-evaluating the resident's condition prior to discharge. The resident, who was admitted with chronic hypoxic respiratory failure, recent subdural hemorrhage status post craniotomy, and protein malnutrition, was highly dependent on staff for all activities of daily living, requiring assistance from one or two helpers for basic care tasks. Despite these significant care needs, the facility only communicated discharge plans verbally and did not issue the required 30-day written notice to the resident or their responsible party. Interviews with the responsible party, clinical manager, and case manager confirmed that the discharge process was handled without proper written notification, and the facility's policy did not specify the 30-day written notice requirement. The responsible party and ombudsman both raised concerns about the lack of written notice and the safety of the discharge plan, especially given the resident's ongoing high level of care needs and the family's preference for transfer to another skilled nursing facility. The facility's failure to follow regulatory requirements for discharge notification and planning was confirmed through record review and staff interviews.
Failure to Promote Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not ensuring proper communication and privacy during care. In the first instance, a Licensed Vocational Nurse addressed a resident with a term of endearment ('honey') instead of using the resident's name or appropriate title prior to administering medication. The resident in question had severe cognitive impairment and was dependent on staff for all activities of daily living. Facility policy and staff interviews confirmed that residents should be addressed by their names or titles to maintain respect and dignity. In the second instance, a Certified Nurse Assistant provided incontinent care to another resident without fully drawing the privacy curtain or closing the room door, leaving the resident exposed. This resident also had severe cognitive impairment and was dependent on staff for personal care. The care plan for this resident specifically included interventions to provide privacy during personal care. Staff interviews acknowledged the importance of maintaining privacy and dignity during such procedures, and facility policy emphasized the preservation of patient rights and dignity.
Failure to Set Low Air Loss Mattresses Correctly for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and care by not ensuring that low air loss mattresses (LALM) were set according to residents' weights, as required by facility policy and physician orders. For three residents, the LALM settings were observed to be incorrect during multiple observations and interviews. Specifically, one resident with a history of cerebrovascular accident, right-sided hemiplegia, and high risk for pressure ulcers had their LALM set at a lower zone than required for their weight, despite care plans and physician orders specifying the need for correct settings. Nursing staff confirmed the mattress was set incorrectly and acknowledged that improper settings could worsen pressure injuries. Another resident, diagnosed with Parkinson's disease, chronic respiratory failure, and a stage 4 pressure ulcer, was also found with their LALM set below the appropriate zone for their weight. This resident was highly dependent for all activities of daily living and had multiple pressure ulcers upon admission. Staff interviews confirmed the mattress was not set according to the resident's weight, and that this could compromise wound healing, as the therapeutic effect of the mattress would not be effective if set incorrectly. A third resident, with severe cognitive impairment and a history of healed pressure ulcers, was observed with their LALM set at a lower zone than required for their current weight. Staff confirmed the mattress should have been set higher and that incorrect settings could lead to skin breakdown. Facility policy and procedure documents reviewed indicated that mattress settings must be appropriate to the resident's weight to provide effective pressure relief and prevent skin breakdown. The failure to follow these protocols was confirmed through staff interviews and record reviews.
Failure to Follow Enteral Medication Administration Protocols
Penalty
Summary
The facility failed to provide appropriate care to prevent complications related to enteral feeding for two residents with gastrostomy tubes. For one resident with chronic respiratory failure, aspiration pneumonia, and diabetes mellitus, a nurse administered medications via the G-tube without turning off the enteral feeding pump, contrary to facility policy. The nurse stated that tube feeding is only held during a specific morning shift and not during other medication administrations. The facility's policy requires that continuous tube feedings be put on hold before administering medications through a feeding tube. For another resident with Parkinson's disease, diabetes mellitus, and a PEG tube, a nurse prepared and administered medications by mixing them together and rapidly pushing the mixture through the G-tube using a syringe plunger. The medications were not given one at a time, nor were they allowed to infuse by gravity as required by facility policy. The nurse stated it was acceptable to mix medications, while the interim DON clarified that medications should be given separately and by gravity, not by force. Facility policies reviewed indicated that tube feedings should be paused before medication administration, medications should not be mixed unless compatible, and medications should be administered by gentle instillation or gravity, flushing between each medication. These procedures were not followed for the two residents, as observed and confirmed by staff interviews and record reviews.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices for five of thirteen sampled residents, as evidenced by multiple direct observations and staff interviews. In one instance, a resident with severe cognitive impairment and total dependence for activities of daily living was observed with a Foley catheter drainage bag resting on the floor and not covered with a dignity bag, contrary to the care plan and facility policy. Both a registered nurse and the interim director of nursing confirmed that the drainage bag should not be on the floor due to infection control concerns and that it should be covered for both dignity and infection prevention. During medication administration and dressing changes, two LVNs did not change gloves or perform hand hygiene between tasks. One LVN, while administering medications to a resident with severe cognitive impairment and multiple comorbidities, picked up a medication bottle from the floor with gloved hands, continued preparing medications without changing gloves, touched various surfaces and the resident’s linens, and administered medications and eye drops—all without changing gloves. The LVN admitted to not being aware of the need to change gloves between tasks. Another LVN, during a G-tube dressing change and medication administration for two different residents, failed to change gloves after touching potentially contaminated surfaces, such as the resident’s clothes and their own mask, before proceeding with invasive procedures. Both LVNs acknowledged during interviews that they should have changed gloves to prevent possible contamination. Additionally, the facility did not ensure that medical equipment was properly cleaned and disinfected. A feeding pump used by a resident with chronic respiratory failure and end-stage ALS was observed with visible brown/yellow stains, and a CNA confirmed that the equipment should be cleaned daily. The infection prevention nurse also stated that daily cleaning of medical equipment is essential for infection control. Facility policies reviewed supported the need for proper hand hygiene, glove changes, and daily cleaning of patient care equipment, but these were not followed in the observed instances.
Failure to Secure Resident Medical Records and Maintain Confidentiality
Penalty
Summary
The facility failed to secure confidential medical records for one resident, as required by its own policy. During an observation, a computer monitor displaying the resident's medication list and personal information, including date of birth, was left turned on and unattended on top of a medication cart in the hallway, directly in front of the resident's room. This allowed the resident's protected health information to be visible and accessible to unauthorized individuals. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes mellitus, and a history of seizures, and was assessed as having severely impaired cognitive skills, being dependent on staff for all activities of daily living. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, confirmed that staff are expected to turn off or blank computer screens when stepping away to comply with HIPAA privacy and security rules. A review of the facility's policy on resident privacy and confidentiality further indicated that all staff must not leave workstations unattended without first logging off or blanking the screen. The failure to follow these procedures resulted in the exposure of the resident's confidential information.
Failure to Monitor Anticoagulant Therapy as Required by Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident receiving Apixaban (Eliquis) for atrial fibrillation. The resident, who had multiple diagnoses including respiratory failure, COPD, and atrial fibrillation, was severely cognitively impaired and dependent on staff for all activities of daily living. The physician's order specified Apixaban administration via gastrostomy tube, and the care plan included interventions to monitor for bruising, bleeding, and the effectiveness and side effects of the medication. However, a review of the resident's progress notes revealed no documentation that nursing staff monitored for side effects or the effectiveness of the anticoagulant therapy as required by the care plan and facility policy. During interviews, the MDS Coordinator confirmed that the lack of documentation indicated staff were not checking the resident for bleeding or other side effects while on Eliquis. The facility's policy required assessment and care planning to meet individual resident needs, but this was not followed in this case.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs), including grooming, was observed to have long and untrimmed fingernails on both contracted hands. The resident's medical history included chronic subdural hematoma, respiratory failure, and chronic obstructive pulmonary disease. Assessment records indicated the resident was severely cognitively impaired and required total assistance for toileting hygiene, oral hygiene, and dressing. During an observation, the resident was found lying in bed with long fingernails touching the skin. Certified Nursing Assistant 1 confirmed that the resident's fingernails were long, untrimmed, and in contact with the skin, acknowledging that nail care is part of daily grooming and that long nails could harbor bacteria and potentially cause skin tears. The Director of Staff Development stated that CNAs are responsible for providing grooming care, including nail care, to ADL-dependent residents. Facility policy indicated that grooming activities, including nail care, should be provided as needed for resident hygiene and safety.
Failure to Administer SCDs as Ordered for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents received treatment and care as ordered by not administering sequential compression devices (SCDs) according to physician orders. For one resident with chronic respiratory failure, encephalopathy, and quadriplegia, records showed a high risk for venous thromboembolism (VTE) and a physician's order for SCD use. Observations revealed that the SCD sleeves were either not applied or, when applied, the machine was turned off. Nursing staff confirmed that the SCD should have been in use and acknowledged that the physician's order was not being followed. Similarly, another resident with chronic subdural hematoma, respiratory failure, and chronic obstructive pulmonary disease was also identified as high risk for VTE and had a physician's order for SCD use. Observations found the SCD machine turned off and the sleeves not applied while the resident was in bed. Nursing staff confirmed that the SCD should have been applied and in use as ordered. Facility policy required implementation of appropriate VTE prevention measures based on risk, but these were not followed for the two residents.
Improper Mixing and Administration of Medications via G-Tube
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) mixed Lactulose and Rivastigmine together with water and administered the combined medications via a gastrostomy tube (G-tube) to a resident. The resident had multiple diagnoses, including Parkinson's disease, diabetes mellitus, Alzheimer's disease, and was dependent on a G-tube for medication administration. The nurse prepared the medications by opening the Rivastigmine capsule, mixing its contents with Lactulose and water, and then administering the mixture in two rapid boluses through the G-tube. The facility's policy and procedure specifically instructed staff not to mix incompatible medications and to administer medications one at a time, flushing the tube with water between each medication. The policy also required medications to be administered via gentle instillation or gravity, not by force or rapid bolus. The LVN stated it was acceptable to mix some medications, while the Interim Director of Nursing clarified that medications should not be mixed due to risks such as tube clogging and drug interactions. The nurse's actions were not in accordance with the facility's established medication administration protocols.
Medication Error Rate Exceeds 5% Due to Improper G-Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of 25 observed opportunities, resulting in an 8% error rate. Specifically, a Licensed Vocational Nurse (LVN) prepared and administered Lactulose and Rivastigmine together by mixing the contents of a Rivastigmine capsule with Lactulose liquid and water, then administering the mixture via a gastrostomy tube to a resident. This method of administration was observed during a medication pass and was not in accordance with the prescriber's order, manufacturer's specifications, or accepted professional standards. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes mellitus, a gastrostomy tube, and Alzheimer's disease, and was assessed as having severely impaired cognitive skills and being fully dependent for daily activities. The facility's policy and procedure on medication administration specifically indicated that incompatible medications should not be mixed and that medications should be administered one at a time. The Interim Director of Nursing confirmed during an interview that medications should not be mixed due to risks such as tube clogging and drug interactions.
Failure to Properly Label and Store Food Items in Kitchen
Penalty
Summary
The facility failed to ensure proper storage and preparation of food items served to residents by not labeling refrigerated opened food items with a used by date and not labeling unopened food items that had been removed from their original boxes with the name of the item, expired date, opened date, and used by date. During an observation of the walk-in refrigerator, it was found that an opened container of peeled garlic lacked a label indicating the opened and used by dates. Additionally, several unopened containers of salad dressings that had been removed from their original packaging were not labeled with the required information. Interviews with the Dietary Supervisor and Food Service Director confirmed that these labeling and storage practices were not followed, despite facility policy requiring all prepared and unserved food, as well as items not in their original containers, to be clearly labeled and dated. The failure to adhere to these procedures was acknowledged by staff and was identified as a deficient practice with the potential to result in foodborne illness for all residents consuming food prepared by the facility kitchen.
Failure to Report Change in Resident Condition
Penalty
Summary
The facility failed to adhere to its policy titled 'Change in Resident Condition' by not reporting a bruise sustained on the left leg of Resident 1 to the physician and the resident's next of kin in a timely manner. The bruise, which was approximately 5 cm by 5 cm, was discovered on 11/19/2024, but the physician was not notified until 11/21/2024, two days later. The facility's policy requires that any sudden or serious change in a resident's condition be communicated to the physician and family or legal representative promptly. However, this protocol was not followed, as evidenced by the delayed notification. Resident 1, who was admitted for chronic respiratory failure with hypoxia, had been comatose in the subacute unit for about 9 years. The bruise was discovered by the nursing staff, but there was no history of trauma, swelling, redness, or pain on palpation reported. The resident was not on blood thinners, and lab work was ordered the day before the physician was notified. The resident's daughter was upset upon discovering the bruise during a visit, indicating a lack of communication from the facility regarding the change in condition.
Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to ensure that three residents received necessary treatment and services to prevent the formation and promote the healing of pressure injuries. For Resident 3, the facility did not accurately monitor, assess, and document the resident's skin condition from 4/1/2024 to 4/26/2024. This included failing to measure and document a newly developed stage 2 pressure injury on the right shoulder, as well as failing to measure existing stage 2 and stage 3 pressure injuries on the left and right ischium, respectively. This lack of proper assessment and documentation resulted in the development of a new stage 2 pressure injury on Resident 3's right shoulder and had the potential to delay healing and worsen existing pressure injuries. For Resident 27, the facility did not ensure that the low air loss mattress (LALM) was set according to the resident's weight. The LALM was observed to be set at 315 pounds, while Resident 27 weighed only 117 pounds. This incorrect setting placed Resident 27 at risk of developing pressure injuries due to receiving more pressure than needed while in bed. Both Licensed Vocational Nurses (LVNs) confirmed that the LALM setting was incorrect and emphasized the importance of having the correct setting to prevent skin breakdown. Similarly, for Resident 236, the facility failed to ensure that the LALM was set according to the resident's weight. The LALM was observed to be set at Zone 5 (210 pounds), while Resident 236 weighed 165 pounds. This incorrect setting placed Resident 236 at risk for the progression of pressure injuries. The LVN confirmed that the LALM setting was incorrect and stressed the importance of having the correct setting to ensure comfort and prevent worsening of pressure injuries. The facility's policy and procedure for skin care and the use of pressure-relieving devices were not followed in these cases, leading to the deficiencies observed.
Failure to Follow G-Tube Placement Verification Policy
Penalty
Summary
The facility failed to follow its policy for checking gastrostomy tube (G-tube) placement by auscultating the epigastric area while injecting a small amount of air for two residents. Resident 14, who had severe cognitive impairment and was dependent on assistance for daily activities, experienced coughing and stomach content backing up into the syringe during medication administration. The Licensed Vocational Nurse (LVN) did not auscultate the epigastric area before aspirating stomach contents, which is a required step to ensure proper G-tube placement. The LVN acknowledged forgetting this step and recognized its importance in verifying the G-tube's position. Similarly, Resident 24, who also had severe cognitive impairment and was dependent on assistance, had their G-tube placement checked by a Registered Nurse (RN) without auscultating the epigastric area. The RN aspirated stomach contents but did not listen for abdominal sounds, which is necessary to confirm the G-tube is correctly positioned. The RN admitted to forgetting this step and noted that the head of the bed should be elevated higher than 30 degrees to reduce the risk of vomiting. The facility's policy clearly states the need to auscultate the epigastric area while injecting air to check G-tube placement, which was not followed in these instances.
Failure to Provide Necessary Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents by not having emergency equipment available in the activity room for accidental decannulation. Resident 4, who had a history of seizure disorder, hypertension, and chronic respiratory failure with a tracheostomy, was observed in the activity room without a respiratory therapist present and without necessary emergency equipment. Similarly, Resident 28, with a history of acute respiratory failure and a tracheostomy, and Resident 34, with chronic respiratory failure and a tracheostomy, were also observed in the activity room without the required emergency equipment or a respiratory therapist present. During interviews, the Activities Assistant and the Registered Nurse Supervisor confirmed that residents with tracheostomies did not bring their trach kits, inner cannulas, or obturators to the activity room. The Respiratory Therapist stated that each resident should have a spare trach and an Ambu bag with them at all times, but was unsure of the facility's policy regarding this. The Director of Nursing and the MDS Coordinator also confirmed that residents did not need to bring their trach kits to the activity room, which contradicted the facility's policy. The facility's policy, as reviewed and confirmed by the Director of Nursing, indicated that there must be two staff members present in the activity room at all times, including a respiratory therapist, and that an Ambu bag, oxygen, and a spare trach must always accompany the resident. The lack of adherence to this policy resulted in the potential for respiratory distress for the residents with tracheostomies during accidental decannulation.
Failure to Ensure Safe Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not disposing of expired medication, not properly storing medications, and not keeping medication carts locked. During an observation of Medication Cart 1, a Desitin diaper rash paste with an expired date was found, and the drawers were observed to be dusty. The Registered Nurse Supervisor acknowledged the importance of discarding expired medications and maintaining cleanliness to prevent infections. The facility's policy indicated that storage, administration, and documentation of medications should be managed to maintain patient safety. Resident 4, who had a history of seizure disorder, hypertension, chronic respiratory failure, and other conditions, was found to have a Primidone medication blister packet on the floor by their doorway. The Director of Nursing confirmed that the medication should not have been on the floor. The Licensed Vocational Nurse who administered the medication stated that the blister packet was not on the floor when she entered the room and acknowledged that medications should not be left on the floor to prevent unauthorized access. Additionally, medication carts were observed to be unlocked and unattended, allowing staff to access medications without entering a code or using a key. Licensed Vocational Nurses and the Director of Pharmacy confirmed that medication carts should always be locked to prevent theft, tampering, and unauthorized access. The facility's policy stated that medications should be stored securely and that medication carts should be locked when unattended to ensure resident safety.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to follow proper food handling practices in accordance with its policy and procedure. Specifically, the facility did not label food in the kitchen with item names, dates opened, and expiration dates. Observations revealed that containers of rice, flour, oyster sauce, and salsa were not properly closed, and frozen chicken, sherbet, and ranch dressing lacked appropriate labeling. The Dietary Staff and Dietary Supervisor confirmed that all food items should be labeled to prevent contamination and ensure food safety, as per the facility's policy revised in February 2022. Additionally, the facility did not maintain clean kitchen surfaces. Dust was observed on the shelves and windowsill near the tray line table, and there was a pool of water on the tray line table surface. The Dietary Director acknowledged the importance of keeping surfaces clean and dry to prevent food contamination. Furthermore, personal belongings, specifically two hooded jackets, were found hanging in the kitchen storage room, which the Dietary Director stated could lead to food contamination. The facility's policy mandates that all food be covered, labeled, and stored appropriately, with expiration dates adhered to and items discarded if expired.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to properly dispose of garbage in the kitchen by not having lids on the garbage containers, contrary to the facility's policy and procedure. During an observation and interview with the Dietary Director (DTD), multiple uncovered garbage cans were noted in the kitchen. The DTD initially stated that it was acceptable not to have covers to avoid touching the lid each time trash was disposed of. However, during a later interview and record review, the DTD acknowledged that the facility's policy required fitting lids on garbage cans to prevent food contamination. The garbage can in the dirty dishwashing area was also observed to be full and uncovered, further contributing to the unsanitary conditions.
Failure to Maintain Resident Dignity and Infection Control
Penalty
Summary
The facility failed to promote respect and dignity for a resident by not ensuring the resident's indwelling catheter urine collection bag was inside the dignity bag. The resident, who was alert and oriented, had an indwelling catheter and was dependent on assistance for daily activities. During an observation, it was noted that the catheter bag was not covered by the dignity bag, and the urine was exposed. Additionally, the catheter bag and tubing were touching the floor, which was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the importance of covering the bag for dignity and infection control. Further interviews with the Minimum Data Set Coordinator (MDSC) confirmed that the catheter bag should be fully covered and not touching the floor to maintain dignity and infection control. The facility's policy on Resident Privacy and Confidentiality emphasized the importance of treating residents with respect and ensuring their dignity and privacy. The failure to adhere to this policy resulted in a potential loss of dignity and self-esteem for the resident.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a homelike environment for one of the sampled residents by using the resident's room to store three hospital computer workstations and a tablet stand. Additionally, the facility did not replace a broken window screen, leaving it propped against the wall, and left a used disposable plastic cup on the floor next to the trash. These actions were observed during a survey and were confirmed through interviews with the MDS Coordinator and the Director of Nursing, who both acknowledged that the resident's room should not be used for storing facility equipment and that the room should be maintained in a homelike manner. The resident involved had a history of hypertension, type 2 diabetes mellitus, ventilator-dependent respiratory failure, and a tracheostomy. The resident was assessed as having severely impaired cognitive skills and was dependent on assistance for daily activities such as eating, oral hygiene, bathing, and dressing. The facility's policy and procedure emphasized the importance of creating a homelike atmosphere to enhance the well-being of residents, but this was not adhered to in the case of this resident, leading to an unsanitary and unkempt environment that could negatively impact the resident's quality of life.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the Nurse Staffing Information posted was complete by not reflecting the total and actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This was observed on 4/27/2024 at 11:11 AM, where the Daily Posted Nurse Staffing for the 7 am to 3 pm shift indicated a census of 38 but did not include the total and actual number of hours worked for both licensed and unlicensed nursing staff. The Unit Secretary confirmed that the posting on 4/26/2024 also lacked this information for each shift. Further review of the Daily Posted Nurse Staffing from 4/21/2024 to 4/26/2024 revealed that the postings included the census and the total number of RNs, LVNs, and CNAs but did not include the total and actual worked hours per shift for licensed and unlicensed nursing staff. The Director of Nursing confirmed this deficiency and stated that the facility did not have a policy for Daily Posted Nurse Staffing to be compliant with the regulation.
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What surveyors actually found near you
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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 San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ivy Creek Healthcare & Wellness Centre | 0 mi | ★★★★★ | 1 | 0 |
| Live Oak Rehab Center | 0.2 mi | ★★★★★ | 36 | 1 |
| Royal Vista Care Center | 0.5 mi | ★★★★★ | 30 | 0 |
| Broadway Healthcare Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 1 mi | ★★★★★ | 1 | 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 June 2026) and official state health department websites.