San Gabriel Conv Center

In the surveyor’s words

From the most serious findings on record at San Gabriel Conv Center, in the surveyor’s own words.

• Actual harm, isolatedF678May 23, 2025

  Based on interview and record review, the facility failed to provide immediate, effective and uninterrupted basic life support (BLS - a set of emergency medical procedures designed to maintain life in individuals experiencing cardiac arrest, respiratory failure, or other life-threatening conditions) and cardiopulmonary resuscitation (CPR) on [DATE] for one of three closed record sampled residents (Resident 119), who was identified full code in the facility and found unresponsive and not breathing, in accordance with the facility ' s P&P, by failing to: 1. […]

• No harm, potential for more than minimal, patternF757Jun 18, 2026

  Based on observation, interview and record review the facility failed to ensure two of three sampled residents (Resident 6 and 76) was free from unnecessary drugs as indicated in the facility's policy and procedure titled Medication Therapy. 1. For Resident 6 the facility failed to ensure: a. Journavx (a medication used for moderate to severe acute pain) was not administer ed for excessive periods of time from 3/29/2026 to 6/16/2026 while the pharmaceutical recommended to use for the drug for shortest duration, consistent with individual patient treatment goal. b. Journavx pharmaceutical recommendation indicated for moderate to severe acute pain, while Resident 6's was administered Journavx from 4/1/2026 to 6/15/2026 for pain level documented as zero (0) and administered for 148 times. c. […]

• No harm, potential for more than minimal, patternF812Jun 18, 2026

  Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice and the facility's policy and procedure titled, Sanitation and Infection Control and Dating and Labeling for food service safety and maintain sanitary food handling practices by failing to discard an expired food item dated 3/28/2026 and wash hands after performing a different task before returning to put away clean dishes. This deficient practice had the potential for contamination of food, clean food-contact items and for residents to be at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). […]

• No harm, potential for more than minimal, patternF880Jun 18, 2026

  Based on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled Infection Control, unknown date, of maintaining an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection by failing to ensure: 1. Restorative Nursing Assistant (RNA) 1 assisting three of 13 sampled residents (Resident 57, Resident 91, and Resident 97) with their meals performed hand hygiene after leaving each resident and before assisting the next resident. […]

• No harm, potential for more than minimal, patternF578May 23, 2025

  Based on interview and record review, the facility failed to ensure two of five sampled residents' (Resident 81 and 99) Physician Orders for Life Sustaining Treatment (POLST forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) and Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) Acknowledgment Form correctly indicated Resident 81 ' s and 99 ' s Advance Directive. […]