San Gabriel Valley Medical CTR D/P SNF

In the surveyor’s words

From the most serious findings on record at San Gabriel Valley Medical CTR D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Apr 27, 2026

  Based 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).Findings: During a concurrent observation and interview of the Nurse's Station, on 4/25/2026, at 3:24 PM, Med Cart 2 was left unattended and unlocked. […]

• No harm, potential for more than minimal, patternF812Apr 27, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880Apr 27, 2026

  Based 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.Licensed Vocational Nurse 3 (LVN 3) failed to don (put on) and doffed (the safe and orderly removal) personal protective equipment (PPE, such as gowns, masks, goggles, gloves) during… […]

• No harm, potential for more than minimal, patternF921Apr 27, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF550Mar 28, 2025

  Based 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. Findings: 1. During a review of Resident 12's Admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. […]