Mount San Antonio Gardens

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.