San Gabriel Valley Medical Ctr D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 2 medication carts (Med Cart) were not left unattended and locked at all times in accordance with the facility's medication management policy. This deficient practice had the potential for unauthorized access to medications by staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food-handling procedures and to maintain the food service area in a clean and sanitary manner, in accordance with the facility's policies and procedures (P&P) when: One can opener was dirty, had peeled metal lining, and was chipped and rusted. One food processor was cracked and had white, crusty buildup. One clear plastic bag of breaded chicken was not labeled with the item name and the open date (date opened or first use). A container of chopped garlic in the refrigerator was not sealed. The rubber seal on the ice machine cover door was cracked and falling apart. A container of ready-mixed mashed potato powder in the kitchen spice rack was not sealed properly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of four (4) sampled residents (Resident 12 and 36) in accordance with the facility's policy and procedure (P&P) when:Contact isolation precaution (prevent the spread of infections transmitted by direct or indirect contact with a patient or their environment) signage was not posted outside Resident 12's room who was on contact isolation precaution. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to maintain safe, clean, comfortable, sanitary and home-like environment for two (2) of three (3) sampled residents (Resident 21 and 30) reviewed for environment by failing to: 1. Ensure that Resident 21's gastrostomy tube (G-tube pump, an electronic, battery-powered medical device that delivers liquid nutrition, fluids, or medication at a controlled rate directly into a person's stomach through a surgically placed abdominal tube) and pole were free of dried milk residue. 2. Ensure that the power strip, with four power cords plugged in, had electrical cables that were not coiled and tangled with Resident 21's G-tube pump base. 3. Ensure Resident 30's television's (TV's) power cord was not plugged into the distant outlet of the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure the confidential medical records for one (1) of (1) sampled residents reviewed for privacy (Residents 33) as indicated on the facility's policy and procedure (P&P) titled Resident Privacy and Confidentiality. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 33's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment).

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of five sampled residents (Resident 34) reviewed for unnecessary medication, to reflect the resident's diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) which could negatively affect Resident 34's overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one (1) of one sampled resident (Resident 19) reviewed for abuse, by failing to assess and notify the physician after Resident 19 reported hitting his head on the headboard while getting repositioned up in bed (to move a Resident ensure a timely from the foot of the bed back toward the head of the bed) by Licensed Vocational Nurse 4 (LVN 4). This deficient practice has the potential to result in a lack of or delay in delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the activity of resident's preference for one of two sampled residents (Resident 19) reviewed for activities in accordance with Resident 19's Activity Assessment. Resident 19 was not able to watch television for more than a year. This deficient practice resulted in Resident 19 not being able to watch television, which had the potential to affect Resident 19's quality of life, sense of self-worth, and psychosocial (how a person's mental/emotional state interacts with their social environment, relationships, and surroundings) well-being and meaningfulness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a bladder training program (use of a timed schedule for bladder based on the resident's identified need and routine to maximize control of the resident's bladder function as much as possible) was implemented for one (1) of 1 sampled resident (Resident 34) reviewed for bowel and bladder care as indicated on the facility's policy and procedure (P&P) and physician's order. This deficient practice had the potential to prevent the restoration of the resident's bowel and bladder function and contribute to the development of a urinary tract infection (UTI-an infection in any part of the urinary system, including the kidneys, bladder, or urethra).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of five (5) sampled residents (Resident 19 and Resident 36) reviewed and observed for medication administration, in accordance with the physician's order and facility's Policy and Procedure (P&P) by failing to ensure: Licensed Vocational Nurse 2 (LVN 2) administered Resident 19's ferrous sulfate (a supplement used to increase iron levels to support red blood cell production) not exceeding 2 hours of the scheduled dosing time of 8 AM on 4/27/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation of administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 8% for 2 of 5 sampled residents (Resident 19 and Resident 36) observed for medication administration. Licensed Vocational Nurse 2 (LVN 2) administered Resident 19's ferrous sulfate (a supplement used to increase iron levels to support red blood cell production) more than 2 hours of the scheduled dosing time of 8 AM as indicated on the physician's order and facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records were complete and accurately documented for one (1) of 1 sampled resident (Resident 19) reviewed for abuse, (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by failing to document Resident 19's report of hitting his head on the headboard while getting repositioned up in bed (to move a resident from the foot of the bed back toward the head of the bed) by Licensed Vocational Nurse 4 (LVN 4). This deficient practice had the potential to result in incomplete assessment of Resident 19's needs and could lead to a lack of or delay in delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of one sampled residents (Resident 1) by failing to provide a written form of discharge notice to the resident and family members and re-evaluate resident 1's condition for discharge. These deficient practices placed Resident 1 at risk for unsafe discharge. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 2 residents (Residents 12 and 24) by failing to ensure: 1. Licensed Vocational Nurse 1 (LVN 1) address Resident 12 with the resident's name instead of using a label prior to medication administration. 2. The curtain in Resident 24's room was fully drawn and/or the resident's door was closed while Certified Nurse Assistant 1 (CNA1) was providing incontinent care to Resident 24. This deficient practice had the potential to affect Resident 12 and 24's emotional and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LALM, mattress used for residents who are at risk for developing pressure ulcer or already have a pressure ulcer, designed to circulate a constant flow of air) was on the correct settings for three (3) of four (4) sampled residents (Residents 14, 21, and 136) in accordance with the facility's policy and procedure and physician's order. This deficient practice had the potential for Resident 14 and 136 to develop a pressure ulcer and for Resident 21's stage 4 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care to prevent complications of enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) for two (2) of 2 sampled residents (Resident 12 and 4) in accordance with the facility's policy and procedure by failing to: 1. Turn off the enteral feeding pump before and during medication administration via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) for Resident 12. 2. Ensure medications were administered by gentle instillation or gravity via syringe into Resident 4's G- tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for five (5) of 13 sampled resident (Resident 26, 12, 4, 32, and 10) in accordance with the facility's policy and procedure when: 1. Resident 26's foley catheter drainage bag (a urine collection bag) was observed touching the floor on 3/25/2025. 2. Licensed Vocational Nurse 1 (LVN 1) failed to change gloves and perform hand hygiene in between tasks during medication administration to Resident 12. 3. LVN 2 failed to change gloves and perform hand hygiene in between task during Resident 32's gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) dressing change 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure the confidential medical records for one (1) of three (3) residents (Residents 4) as indicated on the facility's policy. This deficient practice had the potential to violate the resident's right to confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the resident's representative) and privacy and misuse of Resident 4's Protected Health Information (PHI, any information that relates to an individual's health status, medical history, or treatment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for the use of Apixaban (Eliquis, a prescription medicine used to treat blood clots in the veins of the legs or lungs) by not having a documented evidence to monitor the side effects and effectiveness of the medication for one (1) of 5 sampled residents (Resident 26) as indicated on the facility's policy. This deficient practice had the potential for Resident 26 not to receive the care and treatment if the medication is ineffective and resident suffers from the side effects of Eliquis such as bleeding, which may result in injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 24), who was dependent on the staff, was provided with appropriate care for activities of daily living (ADLs, activities related to personal care including bathing or showering, dressing, personal hygiene, using the toilet, and eating). Resident 24's fingernails on both contracted hands (a condition where the fingers or palm of the hand become permanently bent or curled) were observed long and untrimmed. This deficient practice had the potential for Resident 24 to develop infection, skin breakdown, and injury, which could negatively affect resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of 13 sampled residents (Resident 19 and Resident 24) received treatment and care by failing to administer sequential compression device (SCD, a medical device that uses inflatable sleeves to apply pressure to the legs to help blood flow and prevent clots) as ordered by the physician. This deficient practice had the potential to result in Resident 19 and Resident 24 to develop deep vein thrombosis (DVT, occurred when a blood clot develops in one of the deep veins in the body) which could lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the safe administration of drugs meet the needs of one (1) of five sampled residents (Resident 4) in accordance with the facility's policy and procedure (P&P) by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not mix Lactulose (used to treat constipation) and Rivastigmine (used to treat dementia [a progressive state of decline in mental abilities] in people with Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]) and administer to Resident 4 on 3/27/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication rate of 8% for one (1) of 5 sampled residents (Resident 4) observed during medication administration (med pass). [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food items served to facility residents by failing to ensure: 1. Refrigerated opened food items were properly labeled with used by date 2. Unopened food items were removed from the original boxes were labeled with used by date This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of food or beverages that are contaminated with certain infectious or noninfectious agents) to all residents who consume food by mouth and served by the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to its policy titled Change in Resident Condition by not reporting a bruise sustained on the left leg for one of two sampled patients (Resident 1) to the physician and Resident 1's next of kin (daughter) This failure to escalate and address the bruise in a timely manner potentially compromised the quality and safety of care provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of five sampled residents (Residents 3, 27, and 236) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers- injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure and physician's order by failing to: 1. Accurately monitor, assess, and document Resident 3's skin from 4/1/2024 to 4/26/2024. Facility also failed to measure and document assessment of Resident 3's newly developed stage 2 pressure injury (when the wound extends into the bottom layers of the skin) on the right shoulder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to check gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) placement by auscultating the epigastric (upper central region of the abdomen) area while injecting a small amount of air for two (2) of two (2) sampled residents (Residents 14 and 24). This deficient practice had the potential for Resident 14 and 24 to aspirate (when something enters the airway or lungs by accident) which can lead to lung problems such as pneumonia (a lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three (3) of three (3) sampled residents (Resident 4, 28, and 34) by failing to provide emergency equipment in the activity room for accidental decannulation (the process whereby tracheostomy [trach- a surgically created hole in the windpipe that provides an alternate way of breathing)]tube is removed) for a resident with a tracheostomy in the activity room. This deficient practice had the potential for Residents 4, 28, and 34 to have respiratory distress during accidental decannulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated on the facility policy by failing to: 1. Dispose expired medication found in Medication cart 1 drawer. This deficient practice had the potential for adverse reaction in the event that expired medication was administered to the residents. 2. Ensure Resident 4's Primidone (Mysoline, a medication used to treat convulsions) was stored and not found on the floor by Resident 4's doorway. 3. Ensure medications were kept locked at all times to prevent unauthorized access of the medications in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food in the kitchen with item name, date opened, and expiration date. 2. Ensure kitchen surfaces were clean. 3. Ensure there were no personal belongings stored in the kitchen storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) which could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly dispose garbage in the kitchen by failing to have a lid on the garbage containers in accordance with the facility's policy and procedure. This deficient practice had the potential to attract pests and rodents contributing to an unsanitary kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Residents 236) by not ensuring Resident 236's indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) urine collection bag was inside the dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). This deficient practice had the potential for Resident 236 to experience loss of dignity and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 3) was provided a homelike environment in accordance with the facility's policy and procedure by: 1. Using Resident 3's room to store 3 hospital computers workstations (used to store resident medication records and for documentation) and one tablet stand (used by facility staff, residents, and families to translate or for video calls). 2. Not replacing the window screen in Resident 3's room and leaving it propped against the wall. 3. Leaving a used disposable plastic cup on the floor next to the trash in Resident 3's room. This deficient practice had the potential for an unsanitary and unkempt resident environment and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Nurse Staffing Information posted was complete by failing to reflect the total and actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential for the Nurse Staffing Information not to be available to the residents and visitors at any given time.