Mount San Antonio Gardens

In the surveyor’s words

From the most serious findings on record at Mount San Antonio Gardens, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Jun 24, 2026

  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. […]

• No harm, potential for more than minimal, patternF695Jun 24, 2026

  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. […]

• No harm, potential for more than minimal, patternF880Jun 24, 2026

  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… […]

• No harm, potential for more than minimal, patternF812May 16, 2024

  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 [DATE], 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. […]

• No harm, potential for more than minimal, patternF688May 26, 2023

  Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of six sampled residents (Resident 21 and 20) with limited range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility. a. For Resident 21, who was left-hand dominant with left sided weakness, the facility failed to complete Rehabilitation Screening Forms in accordance with the facility's policy and provide and provide an adequate exercise program to maintain Resident 21's ROM in both arms as indicated by the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) discharge recommendations, dated 1/22/2022. b. […]