San Gabriel Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Sep 12, 2025

  Based on interviews and record reviews, the facility failed to ensure residents had the right to be free from physical abuse by staff for 1 of 3 (Resident #1) residents reviewed for abuse. The facility failed to ensure Resident #1 was not physically abused by CNA A after Resident#1 suffered pain and fear after incontinent care was provided roughly by CNA A, using a dry towel and a healing labial skin tear was identified on 06/03/25. CNA A provided incontinent care to Resident #1 again with a dry towel and Resident #1 told CNA A not to come into her room. CNA A continued to provide care to Resident #1 until the day before her discharge on [DATE]. […]

• Immediate jeopardy, isolatedF610Sep 12, 2025

  Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 3 residents (Residents #1) reviewed for abuse and neglect. The facility failed to investigate and report abuse when Resident #1 suffered pain and fear after incontinent care was provided roughly by CNA A, using a dry towel and a healing labial tear was identified on 06/03/25. CNA continued to provide incontinent care to Resident #1 until the day before her discharge on [DATE]. […]

• Immediate jeopardy, isolatedF689Mar 18, 2025

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not leave the facility without supervision and/or staff knowledge as she was found in the street in front of the facility by visitors of the facility on 02/23/2025. An Immediate Jeopardy (IJ) was identified on 03/17/2025. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 03/18/2025 the facility remained out of compliance at a scope of isolated and a severity level of not actual harm because all staff had not been trained on elopement. […]

• No harm, potential for more than minimal, patternF600Apr 30, 2026

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 3 of 8 residents (R #3, R #4 and R #5) reviewed for abuse. The facility failed to ensure R#1did not hit R# 3 on the chest 3 times at the lunch table in the dining room for an unknown reason on 04/15/2026. The facility failed to ensure on 4/26/2026 at 10:30 am, R # 4 and R#1 did not get into an altercation when R#4 accidently bumped his wheelchair into R#1s wheelchair by the nurse's station. The facility failed to ensure Resident #1 did not hit R# 5 when R# 5 was would not allow R# 1 to play dominoes on 04/26/2026 at 2:15 pm. This failure could place residents at risk of abuse, physical harm, mental anguish and/or emotional distress. […]

• No harm, potential for more than minimal, patternF695Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 6 residents (Resident #1, Resident#2 and Resident #3) reviewed for respiratory care.The facility failed to ensure the nebulizer masks and tubing of Resident #1, Resident #2 and Resident #3 were stored safely in protective bags.This failure placed residents at risk for respiratory infections through contamination.Findings included:Record review of Resident #1's face sheet, dated 04/30/26, reflected Resident #1 was admitted to the facility on [DATE]. […]