Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 San Gabriel Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with epilepsy and schizoaffective disorder, who had a documented history of verbal and physical behaviors toward others, repeatedly struck other residents in common areas despite having a behavior-focused care plan. On one occasion, the resident hit another female resident three times in the chest at a lunch table, causing the victim to cry and report being struck without provocation. On another occasion, after two residents’ wheelchairs bumped near the nurse’s station, the behaviorally impaired resident and a male resident began striking each other until separated by an RN. Later that day, the same aggressive resident hit a female peer multiple times on the arm during a domino game after being refused participation, an event witnessed by another resident and again observed by crisis officers and nursing staff. These events occurred even though the facility’s abuse policy requires ongoing assessment and monitoring of residents with aggressive histories and intervention to safeguard residents from abuse by other residents.
Surveyors found that three residents with significant respiratory conditions, including COPD, asthma, chronic respiratory failure, and oxygen therapy needs, did not receive respiratory care consistent with professional standards and their care plans. Nebulizer masks and tubing for these residents, which were ordered to be kept bagged when not in use, were observed lying openly on tables rather than being cleaned and stored in protective bags. An RN and an LVN acknowledged responsibility for bagging the equipment and recognized that unprotected equipment could lead to contamination, while the DON confirmed that facility practice and policy require cleaning and bagging of respiratory devices after use. Record review also showed there had been no in-service education on safe handling of respiratory equipment during the period reviewed.
A resident with multiple complex medical conditions did not receive a physician-ordered medication for tardive dyskinesia as scheduled due to delays in obtaining a signed order and the medication not being in stock at the pharmacy. The DON initially placed a verbal order, but the pharmacy required a written, signed order, which was sent several days later. The medication was then found to be out of stock and had to be ordered from the manufacturer, resulting in missed doses.
A resident with multiple comorbidities and dependent on staff for toileting reported being physically abused by a CNA during incontinent care, experiencing pain and fear when a dry towel was used on a healing skin tear. Despite reporting the incident to staff, there was no documentation of her complaints, no evidence of a thorough investigation, and the CNA continued to provide care to the resident. Staff interviews revealed inconsistent awareness and response, and the administrator did not document or investigate the allegation, resulting in an Immediate Jeopardy finding.
A resident with multiple medical conditions, including incontinence and dependence on staff for toileting, reported experiencing pain and fear after a CNA provided rough pericare using a dry towel. Despite the resident reporting the incident to several staff members, there was no documentation of a thorough investigation, no immediate assessment, and the CNA continued to provide care. The facility failed to follow its own policies for reporting, investigating, and protecting the resident during the process, resulting in a deficiency and Immediate Jeopardy.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations that mandate residents remain free from unnecessary restraints.
The facility did not provide adequate nursing staff to meet all resident needs and failed to have a licensed nurse in charge on every shift, as observed through staffing records and facility review.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this finding.
A resident with a diagnosis of psychotic disorder and depression was admitted with a negative PASRR Level 1 screening, despite clear indications of mental illness. Facility staff later confirmed that the resident's diagnoses should have triggered a positive Level 1 PASRR and subsequent Level 2 evaluation, but this was not completed, resulting in the resident not being properly assessed for specialized services.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A box of Novolin 70/30 insulin prescribed to a resident with diabetes was found on a medication cart after its expiration date, despite facility policy requiring timely removal of expired medications. Both the RN and DON acknowledged awareness of the policy, and the expired medication remained accessible even though non-expired insulin was available.
The facility did not establish or maintain an infection prevention and control program as required, as identified by surveyors through observation and review of facility practices.
Three residents with cognitive impairment, mobility issues, and incontinence were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed awareness of the requirement, but observations showed call lights on the ground or under beds, preventing residents from requesting assistance.
A resident with dementia and a history of exit-seeking behaviors was able to leave the facility unsupervised by following visitors out the front door. Staff interviews revealed inconsistent knowledge of elopement protocols, incomplete training, and poor communication regarding sign-out procedures. The resident was found in the street by visitors, highlighting failures in supervision and adherence to established elopement prevention policies.
An RN left a treatment cart unlocked and unattended, contrary to facility policy requiring secure storage of drugs and biologicals. The ADON and DON acknowledged the risk of unauthorized access to medicated creams and cleansers, which could be harmful if misused.
A resident with a history of liver cirrhosis and chronic pain was harmed during a Hoyer lift transfer when CNA B failed to follow proper procedures, resulting in the resident being hit in the head and foot. Despite the resident's cries of pain, CNA B did not stop the transfer or seek assistance, leading to physical harm and emotional distress. CNA C, who was present, confirmed the rough handling and lack of adherence to transfer protocols.
Two residents experienced accidents due to improper transfer techniques by CNAs. One resident, requiring extensive assistance, was transferred without a Hoyer lift or a two-person assist, resulting in a fall and injury. Another resident was roughly handled during a Hoyer lift transfer, causing their head and foot to hit the wall. These incidents highlight failures in adhering to transfer protocols and ensuring resident safety.
A CNA in an LTC facility failed to follow proper hand hygiene procedures while caring for residents, despite being trained on infection control. The CNA was observed handling items and assisting residents without washing or sanitizing her hands, posing a risk of contamination and infection. Other staff members confirmed their training in hand hygiene, and facility policies emphasized its importance, yet the CNA's actions did not align with these standards.
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans. One resident, severely cognitively impaired and at risk of falling, had her call light tucked under the mattress, while another resident with impaired mobility found her call light on the floor. Staff interviews confirmed the expectation for call lights to be accessible, highlighting a lapse in adherence to facility policy.
A resident with severe cognitive impairment and mobility issues was found with bed rails in place without a physician's order or proper documentation. The facility failed to ensure the resident's freedom from unnecessary physical restraints, as the bed rails were not required to treat medical symptoms. Staff interviews revealed a lack of awareness and proper documentation regarding the use of side rails, leading to the deficiency.
A facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. One resident's MDS did not reflect the use of bed rails, while another's dementia diagnosis was inaccurately coded as a psychotic disorder. Staff interviews revealed inconsistencies in assessment and documentation processes, contributing to these deficiencies.
Two residents were admitted to the facility without baseline care plans being completed within the required 48-hour timeframe, potentially risking their care. One resident had acute kidney failure and other conditions, while the other had cellulitis and paraplegia. Despite having comprehensive care plans from prior stays, the absence of timely baseline care plans meant their immediate needs were not formally documented. Interviews revealed that charge nurses were responsible for this task, but a breakdown in the process occurred, possibly due to new staff.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident's care plan did not include side rails despite a history of falls, while another resident, who was non-verbal, lacked a functioning communication system to call for assistance. These deficiencies placed the residents at risk of not having their care needs adequately assessed and met.
A resident with severe cognitive and physical impairments was not provided with a functional communication system to call for assistance. The standard call light system was ineffective due to the resident's inability to use her arms or hands, and the care plan did not address alternative communication methods. Despite staff efforts to replace the call button with a paddle, the resident's needs remained unmet, highlighting a deficiency in the facility's care planning.
The facility failed to ensure that residents had access to a functioning call light system, affecting two residents with significant medical conditions and fall risks. Both residents reported issues with the call lights, and observations confirmed the malfunction. Staff and administration were unaware of the problems, despite maintenance logs indicating previous notifications.
Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse by another resident with known behavioral issues. A female resident with epilepsy, schizoaffective disorder (bipolar type), and hypertension, who had a BIMS score of 8 indicating moderate cognitive impairment, had a care plan revised on 02/17/26 for mood and behavior needs, including rejection of care and verbal and physical behaviors directed toward others. Interventions included administering medications as ordered, monitoring effectiveness, assessing whether behavior endangered herself or others, intervening if necessary, and offering preferred activities. Despite this, on 04/15/26 around noon, staff were alerted by shouting in the dining room and found another female resident crying and reporting that she had been struck three times on the chest by the behaviorally impaired resident while seated at the lunch table. A witness resident also stated that the aggressor had struck the victim. The same resident with behavioral issues was involved in additional altercations with other residents later in April. On 04/26/26 at around 10:30 a.m. near the nurse’s station, a male resident with Parkinsonism, Lewy body–related cognitive changes, and type 2 diabetes, and with a BIMS score of 13 indicating intact cognition, accidentally bumped his wheelchair into the aggressor’s wheelchair. An RN at the nurse’s station heard shouting and observed both residents’ wheelchairs locked together while they were striking each other. The male resident later reported that after the accidental bump, the aggressor “took a swipe” at him and that he hit her back. This male resident required setup or clean-up assistance for some ADLs and substantial/maximal assistance with toileting and bathing, and his care plan focused on his refusal of assistance with eating, but did not address risk of involvement in altercations. Later that same day in the afternoon, the behaviorally impaired resident struck another female resident during a game of dominoes in the dining room. This third resident, who had a history of cerebral infarction, type 2 diabetes, and morbid obesity, had a BIMS score of 12 indicating moderate cognitive problems and required setup or clean-up assistance for some ADLs and substantial/maximal assistance with toileting and bathing. She reported that when she refused to allow the aggressor to join the domino game because of prior difficulty completing the game, the aggressor hit her three times on the right arm. Another resident who was playing dominoes with her witnessed the incident and confirmed that the aggressor began hitting the resident’s right arm when she became angry about not getting what she wanted. During a later assessment by crisis officers and nursing staff, the aggressor was again observed striking this same resident three times on the right arm. These repeated incidents show that, despite the resident’s documented history of verbal and physical behaviors toward others and the facility’s abuse/neglect policy requiring ongoing assessment, care planning, monitoring of residents with aggressive histories, and protection of residents from abuse by other residents, the facility did not prevent the aggressor from repeatedly hitting other residents in common areas. The facility’s own abuse/neglect policy, revised 11/01/17, defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and requires that residents with special needs such as a history of aggressive behavior or entering other residents’ rooms receive ongoing assessment, care planning, and monitoring. The policy also states that when another resident is accused of abuse, the facility will intervene and take appropriate steps to safeguard the resident during and after the investigation. Interviews with the DON and ADM confirmed awareness of the incidents and of the resident’s behavioral history, including prior episodes such as attempting to leave the facility and pulling a receptionist’s hair and punching her. Nonetheless, the behaviorally impaired resident remained in situations where she could and did strike other residents in the dining room and near the nurse’s station, demonstrating that the facility failed to ensure residents were free from abuse by not effectively preventing or controlling the aggressor’s repeated physical contact with other residents.
Improper Storage of Nebulizer Equipment and Failure to Follow Respiratory Care Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards, residents’ care plans, and physician orders for three residents who required nebulizer treatments and oxygen-related equipment. For one resident with acute and chronic respiratory failure, muscle weakness, shortness of breath, diabetes, and dementia, the physician ordered ipratropium-albuterol nebulizer treatments. For another resident with COPD, obstructive sleep apnea, end stage renal disease, type 2 diabetes, and other conditions, the MDS documented oxygen therapy and the care plan and physician orders required that nebulizer masks and tubing be kept bagged when not in use. A third resident with COPD, asthma, chronic respiratory failure, hypertension, dementia, and shortness of breath had a care plan and physician orders for scheduled nebulized budesonide and an intervention to keep nebulizer mask and tubing bagged when not in use. On the survey date, observations in multiple rooms showed that all three residents’ nebulizer masks and tubing were lying openly on tables and were not stored in protective bags as required. One resident reported receiving nebulizer treatment that morning administered by a nurse, and another resident reported receiving morning nebulizer medication for breathing issues, also administered by a nurse, but could not recall who removed the mask. The third resident was unavailable for interview due to being out of the facility for an appointment. These observations demonstrated that, after use, the respiratory equipment was left exposed to the environment instead of being cleaned and stored in a clean protective bag. In interviews, the RN responsible for one resident acknowledged she was tasked with bagging the mask and tubing and stated that failure to protect the equipment from environmental exposure created a risk of cross-contamination and microorganism colonization leading to respiratory and other infections. The LVN responsible for the other two residents stated she usually stored nebulizer masks immediately after medication administration but was unsure what happened on the day of observation, suggesting that residents or family might have removed the masks from the packets, while also acknowledging she was ultimately responsible for ensuring safe storage. The DON stated that nebulizer masks, tubing, and oxygen nasal cannulas should be cleaned and stored in a clean protective bag after use to minimize the risk of respiratory infections and that nurses were responsible for completing this process and conducting regular rounds to verify proper storage. Record review showed no in-service education on safe handling of respiratory equipment during the reviewed period, despite a facility policy requiring safe, appropriate respiratory treatment and adherence to infection control practices for handling and storing respiratory equipment.
Failure to Provide Timely Pharmaceutical Services for Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition and administration of a physician-ordered medication, Ingrezza 80 mg, prescribed for tardive dyskinesia. The resident, a 68-year-old female with multiple diagnoses including pneumonia, acute respiratory failure, anxiety disorder, and schizoaffective disorder, was dependent, non-verbal, and received medications via a feeding tube. Despite a physician's order for Ingrezza with a specified start date, the medication was not administered as scheduled on several occasions because it was not available in the facility. The delay in medication administration was due to a series of procedural lapses: the DON initially placed a verbal order with the pharmacy, but the pharmacy required a signed order before filling the prescription. The signed order was not sent until several days later, and upon receipt, the pharmacy reported the medication was not in stock and had to be ordered from the manufacturer. The DON was unaware of the stock issue until after the order was submitted, and the resident did not receive the medication as prescribed. Interviews with the family, pharmacy staff, and physician confirmed the medication was not provided as ordered, and there were no alternative medications suitable for administration via feeding tube.
Failure to Protect Resident from Physical Abuse and Inadequate Investigation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for toileting hygiene and had a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and osteomyelitis, reported being physically abused by a CNA during incontinent care. The resident described experiencing pain and fear after the CNA used a dry towel roughly on a healing labial skin tear, despite her requests to use wet wipes and to stop due to pain. The resident reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of her complaints or of a head-to-toe assessment being completed in response. The facility failed to implement protective measures, as the CNA continued to provide care to the resident after the initial complaint. There was no evidence that the CNA was suspended during the investigation period, and documentation in the CNA's personnel file did not reflect any suspension or disciplinary action related to the abuse allegation. Additionally, the care plan and physician orders did not address the labial skin tear, and there was a lack of documentation regarding the resident's complaints of rough treatment or any follow-up assessments. Interviews with facility staff revealed inconsistent awareness and response to the abuse allegation. The administrator did not investigate further, believing the incident did not constitute abuse, and did not document the allegation or conversations with the resident or CNA. Other staff members were either unaware of the complaint or could not recall details of the investigation or protective actions taken. The lack of prompt, thorough investigation and failure to remove the alleged perpetrator from resident care led to the identification of Immediate Jeopardy by surveyors.
Failure to Investigate and Protect Resident Following Allegation of Rough Care
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a female resident with a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and sacral osteomyelitis, who was dependent on staff for toileting and incontinent of bowel and bladder, reported experiencing pain and fear after receiving rough incontinent care from a male CNA. The resident described the CNA using a dry towel during pericare, causing her significant pain and distress, and stated that her requests for gentler care were ignored. She reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of a thorough investigation or immediate protective measures, such as suspension of the alleged perpetrator. The resident's care plan and physician orders did not address the labial skin tear that was identified, and there was no documentation of a head-to-toe assessment or follow-up regarding her complaints of rough treatment. Progress notes and incident reports lacked any mention of the resident's report of rough care or the labial tear, and the CNA continued to provide care to the resident after the initial complaint. Interviews with facility staff revealed inconsistent awareness of the incident, lack of documentation, and failure to follow facility policy, which required immediate reporting, assessment, and suspension of the alleged perpetrator during an investigation. The administrator, who was the designated abuse coordinator, did not document the allegation or her conversations with the resident and CNA, and did not initiate a formal investigation, stating she did not consider the incident to be abuse. The resident later recounted ongoing fear and distress, stating that the CNA continued to provide care after the initial incident and that she felt unsafe and traumatized. Interviews with the medical director and other staff confirmed that the use of a dry towel for pericare was not standard practice and that any complaint of rough treatment should have been documented and investigated. The facility's failure to document, investigate, and report the allegation, as well as to protect the resident during the investigation, constituted a deficiency and resulted in the identification of Immediate Jeopardy.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these fundamental resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency, nor does it mention any particular residents or circumstances involved.
Failure to Complete Accurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to provide an accurate PASRR Level 1 screening for a resident who was admitted with a diagnosis of psychotic disorder with hallucinations and depression. Despite these diagnoses, the resident's PASRR Level 1 screening, completed by the hospital doctor prior to admission, was marked negative for mental illness, intellectual disability, and developmental disability. Upon review, facility staff including the administrator, MDS coordinator, and DON all acknowledged that the resident's diagnoses should have resulted in a positive Level 1 PASRR screening, which would have triggered a Level 2 evaluation. The resident's care plan indicated the use of antipsychotic medication for the treatment of her psychotic disorder, and her MDS assessment showed intact cognitive function. The facility's PASRR policy required that any indication of mental illness, intellectual disability, or developmental disability in the Level 1 screening should prompt a Level 2 evaluation, following state-specific procedures. The failure to identify the resident's mental illness in the PASRR Level 1 screening resulted in the resident not being properly evaluated for specialized services she may have been eligible to receive.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Expired Insulin Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and disposed of in accordance with professional standards, specifically regarding expiration dates. During an observation of a medication cart, a box of Novolin 70/30 insulin prescribed to a male resident with type 2 diabetes was found to have been opened on 05/29/25 and remained on the cart past its 42-day expiration period, which should have been on or before 07/10/25. The expired medication was still present on the cart during the survey, despite the resident having non-expired medication available for administration. Interviews with the RN responsible for administering medications and the DON revealed that both were aware of the policy requiring regular checks for expired medications. The RN acknowledged the expired medication should have been removed, and the DON stated that both the charge nurse and the pharmacist are responsible for ensuring expired medications are not present on the carts. Review of facility policy and the medication's prescribing information confirmed the requirement for proper labeling and timely disposal of opened medications.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence or inadequacy of a program designed to prevent, identify, investigate, and control infections within the facility. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents who were at risk for falls, incontinence, and other health concerns. Observations on the specified date revealed that the call lights for all three residents were found on the ground or under the bed, making them inaccessible. One resident, who was in a wheelchair, attempted to reach the call light on the ground but was unable to do so. The other two residents were observed in bed with their call lights similarly out of reach, and both declined to answer questions during the surveyor's visit. Each of the affected residents had significant medical histories, including dementia, unsteadiness, muscle weakness, incontinence, and a history of falls. Their care plans specifically required that call lights be kept within reach at all times due to their risk factors. Documentation showed that staff had checked on these residents earlier in the day, but the call lights were still not accessible at the time of observation. Staff interviews confirmed that they had been in-serviced on the importance of call light placement and were aware of the policy requiring call lights to be within reach whenever care was provided or when leaving a resident's room. Despite staff training and facility policies, the deficiency occurred because staff did not consistently ensure that call lights were accessible to residents. The facility's own policies and the Guardian Angel Program emphasized the importance of call light accessibility for resident safety and communication. However, the observations and interviews demonstrated a lapse in following these procedures, resulting in residents being unable to summon assistance when needed.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Adherence
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, altered mental status, psychotic disorder with delusions, and anxiety disorder was able to leave the facility unsupervised and without staff knowledge. The resident had a documented history of wandering, confusion, and exit-seeking behaviors, and was identified as an elopement risk on multiple assessments. Care plans and progress notes indicated that the resident was rarely understood, had impaired cognition, and required redirection when entering unsafe areas. Despite these documented risks, the resident was able to follow visitors out the front door and was later found in the street by facility visitors. Interviews with staff revealed inconsistencies and gaps in the implementation of elopement prevention protocols. Some staff members were unaware of the existence or location of the elopement risk binder, and not all staff had received training on elopement procedures. The receptionist on duty at the time of the incident did not recognize the resident as an elopement risk and assumed the resident was leaving with family, failing to verify sign-out procedures. Additionally, there was confusion among staff regarding the process for signing residents out for leave of absence, and communication between nursing staff and reception was inconsistent. The facility's policies required that residents at risk for elopement be identified and monitored, and that residents leaving the facility have written physician permission and be properly signed out. However, these procedures were not consistently followed, as evidenced by the resident's ability to exit the building unsupervised. The lack of staff awareness, incomplete training, and failure to adhere to established protocols directly contributed to the resident's elopement and the resulting deficiency.
Removal Plan
- Resident #1 no longer resides at the facility.
- Elopement Risk evaluations done on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed.
- The Director of Nursing was reeducated by the Clinical Consultant on Accidents and Incidents including: elopement risk and the elopement binder; when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder; validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence; elopement risk assessment process and putting interventions in place based on risks identified.
- All Facility Staff will be reeducated by the Director of Nursing/Designee on Accidents and Incidents including: elopement risk and the elopement binder; when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder; validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence.
- Licensed Nurses will be reeducated by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified.
- Any staff not receiving this education will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation.
- The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder.
- The Director of Nursing/Designee will review the facility activity report in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated.
- The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff of new resident listed in the binder.
- The Medical Director was notified of the Immediate Jeopardy.
- An Ad Hoc Quality Assurance and Performance Improvement Meeting was held to discuss contents of this plan.
- Administrator will oversee compliance of this plan.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with a treatment cart that was left unlocked and unattended by an RN. This incident occurred outside of a resident's room, where the door was closed, indicating that the cart was not within the RN's line of sight. The RN acknowledged the oversight, admitting that the cart should have been locked when unattended, as it allowed potential access to residents or unauthorized individuals. Interviews with the ADON and DON revealed that the facility's policy required medication and treatment carts to be locked when not in use to prevent unauthorized access. The ADON expressed concern that residents or unauthorized staff could access the cart, which contained medicated creams and cleansers that could be harmful if misused. The DON expressed disappointment upon learning of the incident, as it did not align with her expectations for medication storage practices. The facility's policy, revised in April 2024, mandates that all drugs and biologicals be stored securely in locked compartments, accessible only to authorized personnel.
Resident Harmed During Improper Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure the safety and well-being of a resident during a Hoyer lift transfer, resulting in the resident being hit in the head by the lift and having his right foot hit against the wall. The incident occurred when CNA B was transferring the resident from his bed to his wheelchair. Despite the resident expressing pain by crying out, CNA B did not stop the transfer or request an assessment, which made the resident feel neglected and uncared for. The resident involved was a male with a history of alcoholic cirrhosis of the liver with ascites, chronic pain syndrome, anorexia, and altered mental status. His cognitive abilities were intact, as indicated by a BIMS score of 14. The resident was dependent on mechanical lift transfers, as outlined in his care plan. During the transfer, CNA B did not follow proper procedures and ignored the resident's expressions of pain, leading to physical harm and emotional distress. CNA C, who was present during the transfer, confirmed that CNA B was rough and did not listen to his directions. CNA C witnessed the resident being hit in the head and his foot being struck against the wall. Despite being trained on abuse, neglect, and transfer techniques, CNA B's actions during the transfer were inappropriate and did not align with the facility's standards of care.
Improper Transfer Techniques Lead to Resident Accidents
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during resident transfers, leading to accidents involving two residents. In the first incident, a resident with moderate cognitive impairment and extensive assistance needs was improperly transferred by a CNA. The CNA did not use a two-person transfer or a Hoyer lift as required by the resident's care plan. Additionally, the CNA failed to lock the wheelchair brakes, resulting in the resident falling and sustaining a bruised and swollen knee. In the second incident, another resident, who was dependent on transfers, experienced rough handling during a Hoyer lift transfer. The CNA involved did not seek assistance and mishandled the resident, causing the resident's head and foot to hit the wall. This incident was witnessed by another CNA, who confirmed the rough handling and lack of communication during the transfer. Both incidents highlight the facility's failure to adhere to established transfer protocols and ensure the safety and dignity of residents during transfers. The lack of proper technique and communication among staff contributed to the accidents, putting residents at risk of harm and neglect.
Inadequate Hand Hygiene Practices by CNA
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not follow proper hand hygiene procedures while providing care to four residents. The CNA was observed feeding one resident and then adjusting another resident's bib without washing or sanitizing her hands. She continued to handle items and assist other residents without performing hand hygiene, despite being trained on the importance of handwashing to prevent contamination and infection spread. The residents involved in this incident had various medical conditions that made them vulnerable to infections. For instance, one resident had a pressure ulcer and elevated white blood cell count, while another had dementia and difficulty swallowing. These conditions necessitate strict adherence to infection control practices to prevent further health complications. The CNA's failure to sanitize her hands after touching potentially contaminated items posed a risk of food contamination and infection to these residents. Interviews with other staff members, including a Medication Aide (MA), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that they were all trained in hand hygiene and infection control. They acknowledged the importance of washing hands before and after resident contact and the potential consequences of not doing so. The facility's policies and procedures emphasized hand hygiene as a critical component of infection prevention, yet the observed practices did not align with these standards.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is a necessary accommodation for their needs. Resident #8, a severely cognitively impaired female with a history of stroke, muscle weakness, and a risk of falling, was found with her call light tucked under the mattress, making it inaccessible. Her care plan specifically required the call light to be within reach due to her impaired mobility and risk of injury. During an observation, her bed was in the highest position with side rails raised, further complicating her ability to access the call light. Similarly, Resident #38, who is cognitively impaired and requires moderate assistance with activities of daily living, was found with her call light tied to the bed rail and lying on the floor, out of her reach. Despite her care plan also mandating the call light to be within reach due to her impaired mobility and cognition, she reported having to yell for help. Staff interviews confirmed that call lights should always be within reach, and it is everyone's responsibility to ensure this. However, the failure to do so was observed, indicating a lapse in the facility's adherence to its policy and care plans.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically bed rails, which were not required to treat the resident's medical symptoms. The resident, an elderly female with a history of cerebral infarction, muscle weakness, moderate protein-calorie malnutrition, history of falling, and chronic pain, was found to have bed rails in place without a physician's order or proper documentation. The resident's MDS assessment did not reflect the use of bed rails, and there was no care plan addressing their use, despite the resident's severe cognitive impairment and substantial assistance needs for activities of daily living. During an observation, the resident was found in bed with the side rails fully raised, and the call light was out of reach, tucked under the mattress. Interviews with facility staff revealed a lack of awareness and proper documentation regarding the use of side rails. The LVN on duty was unaware of the bed's elevated position and the call light's inaccessibility. The MDS nurse acknowledged the absence of a care plan and order for the side rails, attributing it to a recent audit that led to the discontinuation of side rails for the resident. The facility's policy on restraints clearly states that side rails should only be used when necessary to treat medical symptoms and must be documented with a physician's order. The DON and ADM both acknowledged the oversight, with the ADM suggesting that the resident may have been overlooked during the facility's efforts to minimize the use of side rails. The facility's failure to adhere to its policy and ensure proper documentation and assessment for the use of side rails resulted in the deficiency.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. For one resident, the Minimum Data Set (MDS) assessment did not reflect the use of bed rails, despite observations showing that bed rails were in use. The resident was severely cognitively impaired and required substantial assistance with activities of daily living. The care plan did not include the use of side or bed rails, and there was no documented functional need for them. Interviews with staff revealed a lack of clarity and consistency in the assessment and documentation process regarding the use of bed rails. Another resident's MDS assessment inaccurately coded a diagnosis of dementia as a psychotic disorder. The resident had a primary diagnosis of dementia with psychotic features, but the MDS did not reflect this accurately. Interviews with staff, including the MDS Coordinator and the Regional MDS Consultant, showed differing opinions on the correct classification of the resident's condition. The facility's policy and guidelines for MDS assessments were not consistently followed, leading to discrepancies in the resident's assessment. The deficiencies in the assessment process for both residents were identified through observation, interviews, and record reviews. The facility's failure to accurately assess and document the residents' conditions could have led to inadequate care. Staff interviews highlighted a lack of understanding and consistency in following the facility's policies and guidelines for MDS assessments, contributing to the inaccuracies in the residents' assessments.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop baseline care plans within the required 48-hour timeframe for two residents, which could place them at risk for not receiving necessary care and services. Resident #88, a male with acute kidney failure, cerebral infarction, hypertension, and diabetes, was admitted without a baseline care plan being completed within the specified timeframe. His previous comprehensive care plan indicated unclear speech related to a CVA, requiring extra time to communicate needs, and a risk of being misunderstood. However, the absence of a timely baseline care plan meant that these needs were not formally documented for immediate care. Similarly, Resident #90, a male with cellulitis of the buttock, hypertension, congestive heart failure, and paraplegia, also did not have a baseline care plan completed within 48 hours of admission. His comprehensive care plan from a prior stay noted the need for assistance with ADLs to maintain dignity and hygiene. Despite having a BIMS score indicating no cognitive impairment, the lack of a baseline care plan could have led to gaps in addressing his immediate care needs. Interviews with facility staff, including the ADM, DON, and MDS nurses, revealed that the charge nurses were responsible for completing baseline care plans, but there was a breakdown in the process. The MDS nurses were tasked with checking new admissions to ensure baseline care plans were completed, but this did not occur for Residents #88 and #90. The facility's policy required baseline care plans to be developed within 48 hours, yet this was not adhered to, and the reasons for the oversight were unclear, with new nurses being cited as a possible factor.
Deficiencies in Care Planning and Communication Systems
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not include the use of side rails, despite the resident having severe cognitive impairment and a history of falls. The resident was observed with side rails in place, but there was no care plan or physician's order for their use. Interviews with staff revealed that there was a lack of communication and documentation regarding the necessity and safety of side rails for this resident. Another resident, who was non-verbal and had severe cognitive impairment, was not provided with a functioning communication system to call for nursing assistance. The resident's care plan did not address her inability to use the facility's call light system due to her physical limitations. Observations showed that the call light system was not operational, and alternative methods of communication were not effectively implemented. Staff interviews indicated that the resident was checked every two hours, but there was no specific plan to address her communication needs. The deficiencies in care planning and implementation placed both residents at risk of not having their care and treatment needs adequately assessed and met. The facility's policies on care planning and communication systems were not effectively followed, leading to gaps in the residents' care. The lack of a comprehensive care plan for these residents highlights the need for better coordination and documentation of care needs and interventions.
Failure to Provide Functional Communication System for Resident with Disabilities
Penalty
Summary
The facility failed to provide a functioning communication system for Resident #60, who had severe cognitive and physical impairments, including aphasia, hemiplegia, and seizure disorder. The resident was non-verbal and unable to use her arms or hands, making it impossible for her to utilize the standard call light button designed to be activated with a thumb or finger. Despite these limitations, the resident's care plan did not address her inability to use the call light system or provide alternative methods for communication. During an observation, it was noted that the call light button clipped to Resident #60's bed did not illuminate when activated, indicating a malfunction. The facility's staff, including LVN B, attempted to rectify the issue by replacing the call button with a call light paddle, which also proved ineffective for the resident due to her physical limitations. The maintenance team confirmed the paddle was operational, but it was still not a viable solution for the resident's needs. Interviews with staff revealed that the facility had procedures in place, such as guardian angel rounds, to ensure call light systems were functioning. However, these procedures did not account for residents with specific disabilities that prevented them from using the standard communication systems. The comprehensive care plan for Resident #60 failed to include her communication limitations and did not provide alternative methods to ensure her needs were met, placing her at risk of unmet needs.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call light system, which is essential for requesting staff assistance. This deficiency was identified for two residents, both of whom had significant medical conditions and were at risk for falls. Resident #1, who had a diagnosis of infection, acute respiratory failure, and other conditions, reported that staff did not frequently respond to her call light, and she had to use her personal cell phone to contact the nurse's station. Observations confirmed that the call light in her room was not functioning, and a staff member was unaware of any prior issues but promised to submit a maintenance request. Resident #2, who had severe cognitive impairment and a history of falls, also experienced issues with the call light system. She reported waiting over 30 minutes for assistance, and observations showed that her call light was broken and not functioning. A Licensed Vocational Nurse (LVN) attempted to fix the call light but was unsuccessful. The LVN stated she would submit a maintenance request and check other residents' rooms for similar issues. Interviews with the Director of Nursing (DON), the Administrator, and the Maintenance Director revealed that none were aware of the call light issues. The DON and Administrator both emphasized the importance of a functioning call light system for resident safety. Maintenance logs showed that the Maintenance Director had been notified of call light problems multiple times from January to March 2024, but the issues persisted. The facility's policy on call lights was requested but not provided by the exit interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 327 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Round Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Care Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Bel Air At Teravista | 2.8 mi | ★★★★★ | 4 | 0 |
| Hearthstone Nursing And Rehabilitation | 3.8 mi | ★★★★★ | 7 | 0 |
| Park Valley Inn Health Center | 4.2 mi | ★★★★★ | 9 | 0 |
| Falcon Ridge Rehabilitation | 4.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Gabriel Rehabilitation And Care Center.
100% money-back within 48 hours.
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.