Mount San Antonio Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure,A. Adequate monitoring (supervision from staff) to prevent a fall for one of three sampled residents (Resident 6), who was at high risk for falls. B. Proper placement of sensor alarm (wireless bed alarms that alert staff when a patient gets up from the bed for staff to assist the resident, an intervention used to prevent falls) transmitters (paired with the sensor alarm receiver located inside the resident's rooms [in general]) used to detect the resident's motion for two of three sampled residents (Resident 32 and Resident 34), who were at high risk for falls. This deficient practice resulted in Resident 6 sustaining a fall on 6/15/2026 and had the potential to result in falls with injury to Resident 32 and Resident 34. Findings: A. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a gradual decline in mental ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 47, Resident 17 and Resident 30) received proper respiratory (relating to breathing) care in accordance with the facility's policy and procedures (P&P) and physician's orders by failing to:a. Post Oxygen in Use - No Smoking (signage) in the sign plate holder outside of Resident 17 and Resident 47's rooms in accordance with the facility's policy and procedure (P&P) titled, Oxygen Administration.b. Change Resident 30's nasal cannula (NC - a small plastic tube that fits into the person's nostrils and used to provide supplemental oxygen [02 - a colorless, odorless, tasteless gas essential for living) and 02 humidifier (a medical device attachment used during 02 therapy to add moisture to supplemental 02) every Sunday in accordance with the facility's P&P titled, Oxygen Administration.These deficient practices had the potential to result spark producing activities by visitors due to a lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement infection prevention and control measures for two of five sampled residents (Resident 37 and Resident 1) by failing to ensure:A. Certified Nursing Assistant (CNA) 5 wore personal protective equipment (PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection [the invasion and growth of germs in the body] or illness) while providing care to Resident 37 and Resident 1 who were under Enhanced Barrier Precautions (EBP, extra measures, like wearing gowns and gloves, used during high-contact care activities for residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics [medication used to treat bacterial infections], and these antibiotics can no longer be used to control or kill the bacteria] e.g., residents with wounds or indwelling [resides, exist, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a baseline care plan (CP) was developed and implemented within forty-eight hours of admission for one of five sampled residents (Resident 47), who was on supplemental oxygen (02 - a colorless, odorless, tasteless gas essential for living) therapy.This deficient practice had the potential to result in unmet individualized needs for Resident 47 and the potential to affect the resident's physical and psychosocial well-being.Findings:During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long-standing lung disease causing difficulty in breathing), unspecified, and heart failure, unspecified.During a review of Resident 47's Encounter - Office Visit (EOV), dated 6/22/2026, the EOV indicated Resident 47 did not have decision-making capacity.During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of four corner areas (Corner Area 1) in the facility's kitchen was free of pests on 6/22/2026.This deficient practice had the potential to result in foodborne illness (an illness caused by eating contaminated food) for the residents consuming the food prepared in the facility's kitchen. Findings:During a kitchen tour observation and interview on 6/22/2026 at 8:53 AM, with the Dining Services Manager (DSM), there was a separate area inside the kitchen used for baking and trays with freshly baked cookies placed in a cart. The separate area had unidentified debris and an insect that was not moving on the floor at the back of the oven. The DSM stated there was a dead insect behind the oven and the dead insect was a cricket. The DSM stated all areas of the kitchen needed to be cleaned because food debris or other dirt could attract pest into the kitchen.During an interview on 6/24/2026 at 3:50 PM with the Administrator (ADM), the ADM stated all areas of the kitchen needed to be clean.During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sensor alarms (wireless bed alarms that alert staff when a patient gets up from the bed so staff can go and assist the patient, used to prevent falls) were functioning for, two of four sampled residents (Resident 2 and Resident 3), who were at high risk for falls.This deficient practice had the potential to result in falls and injuries to Resident 2 and Resident 3. Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/20/2021, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), other abnormalities of gait, and mobility.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 2 was able to express ideas and wants, understood verbal content, and had problems with short-term and long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the provision of necessary care and services for one of one sampled resident (Resident 15) when, a. Licensed Vocational Nurse (LVN) 1 failed to notify the Medical Doctor (MD, Resident 15's phycisian) promptly (immediately) of Resident 15's Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/28/2025. This deficient practice had the potential to result in life-threatening consequences and untimely medical treatment for Resident 15. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 1/18/2020, with diagnoses that included chronic obstructive pulmonary disease (COPD, long standing group of diseases that cause airflow blockage and breathing-related problems, make it difficult to breathe) and systolic congestive heart failure (the heart cannot effectively contract with each heartbeat). During a review of Resident 15's Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure adequate perineal (an area lower in the body located between the thighs) care was provided for, one of one sampled resident (Resident 9), who had a history of urinary tract infections (UTI, an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body], sits just in front of the vaginal opening) and as indicated in the facility's Policy and Procedure (P&P) titled, Perineal Care. This deficient practice had the potential to result in a UTI and a physical decline to Resident 9. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 7/6/2017, with diagnoses that included disorders of the bladder, neurocognitive disorder with lewy bodies (a disease associated with abnormal deposits of a protein called Lewy bodies, affects chemicals in the brain. These changes, in turn, can lead to problems with thinking, movement, behavior, mood, and other body functions). During a review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and appropriate use of side (bed) rails for one of one sampled resident (Resident 8) when, 1. The facility failed to complete a side rail assessment that aligned with the physician's order indicating bilateral half [½-equal part] rails times four and did not reflect the side rails used for Resident 8. 2. The facility failed to obtain a side rail consent for Resident 8 that reflected the physician's order for the use of side rails. Resident 8's side rail consent indicated the use of quarter [¼- one of four equal parts of something] side rails to two sides, The consent did not reflect four quarter side rails used for Resident 8. Additionally, there was no documented evidence that indicated the risks and benefits for the use of all four quarter side rails were explained to Resident 8's responsible party (RP). This deficient practiced placed Resident 8 at risk for injury. (Cross Reference F842) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation for the use of side (bed) rails, for one of one sampled resident (Resident 8), as indicated in the facility's policy and procedure (P&P), titled, Charting & Documentation, The facility failed to: 1.Complete a side rail assessment aligned with the physician's order to indicate bilateral half [½-equal part] rails times four, the assessment did not reflect the side rails used for Resident 8. 2.Obtain a side rail consent for Resident 8 that reflected the physician's order for the use of side rails. Resident 8's side rail consent indicated the use of quarter [¼- one of four equal parts of something] side rails to two sides, The consent did not reflect four quarter side rails used for Resident 8. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Resident 8. (Cross Reference F700) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 1/18/2018, with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label/date food items in one of one kitchen (Kitchen 1). This deficient practice could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food given to the residents. Findings: During a concurrent observation and interview on 5/13/2024, at 8:02 AM., with the Purchasing Clerk (PC) during the initial tour of Kitchen 1, the following were observed on the top open shelf of the preparation counter area: 1. An unlabeled 20 oz (ounces, unit of weight) Lawry's Salt-Free 17 Seasoning with less than one fourth contents remaining with a label date Received date 2/27/2024 2. An unlabeled 16 oz Sysco Imperial Ground Nutmeg with three quarters contents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 23) was accurately assessed for elopement risk. This deficient practice had the potential to result in inadequate treatment and care services rendered to Resident 23. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility initially on 4/4/2022 with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), osteoarthritis (degeneration of joint cartilage and the underlying bone) and repeated falls. During a review of Resident 23's Nursing-Elopement Risk Assessment ([NAME]), dated 3/20/2023, indicated Resident 23 had a history of leaving the facility. During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/13/2024 indicated Resident 23 was cognitively intact and able to make needs known. During a review of Resident 23's History and Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) received treatment and care in accordance with the facility's policies and procedures (P&P) by failing to ensure Resident 12's skin tear and edema (swelling caused by too much fluid trapped in the body's tissues) were monitored and cared for adequately. This deficient practice resulted in no improvement to Resident 12's skin tear and edema and caused Resident 12 to feel worried, in addition, the failure had the potential to result in a physical decline to Resident 12. Findings: During a review of Resident 12's admission Record (AR), the AR indicated, Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial fibrillation (an irregular, often very rapid heart rate that commonly causes poor blood flow), essential primary hypertension (high blood pressure) and other specified disorders of bone density and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices to ensure a safe, sanitary, and comfortable environment in accordance with the facility's policy and procedure (P&P) by failing to properly store dirty laundry for one of five sampled residents (Resident 33). This deficient practice had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and/or the development and transmission of disease and infection amongst residents and staff. Findings: During a review of Resident 33's admission Record (AR), the AR indicated, Resident 33 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as a stroke, damage to tissues in the brain due to a loss of oxygen to the area), unspecified, essential primary hypertension (high blood pressure) and unspecified atrial fibrillation ( an irregular, often very rapid heart rate that commonly causes poor blood flow).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.