Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden View Post Acute Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced a breach of privacy and dignity when staff failed to close privacy curtains during care. One resident was exposed during a bed bath, and another during a surgical site check. The facility's policy requires privacy measures to be in place during such procedures.
The facility failed to ensure that call lights were within reach and properly explained to residents, affecting four residents. A resident with severe cognitive impairment had their call light on the floor, while another could not reach theirs due to its placement on an oxygen concentrator. A third resident's call light was tangled on a bed rail, and a fourth resident was not instructed on its use, leaving them to shout for help. Staff interviews confirmed the need for call lights to be accessible and explained, as per facility policy.
The facility failed to provide necessary care for residents with indwelling catheters, leading to potential infection risks. A resident's Foley catheter was not secured and had white sediments, while another's suprapubic catheter was not properly maintained. Nephrostomy tubes for a third resident were positioned incorrectly, and a fourth resident's catheter showed signs of potential infection. Facility policies on catheter care were not followed.
The facility failed to follow its policy on bedrails and grab bars for two residents, leading to deficiencies. For one resident with impaired cognition, grab bars were installed without attempting alternatives or obtaining informed consent. Another resident with intact cognition had bedrails installed without consent or alternative attempts. The facility's policy required assessment and consent, which were not followed.
The facility failed to ensure staff wore required PPE while providing care to residents on Enhanced Barrier Precautions (EBP). A CNA provided care to a resident with a Foley catheter without a gown, an LVN entered a resident's room without PPE to check a G-tube, and another CNA entered a room to provide a bed bath without a gown. These actions were against the facility's infection control policies, risking the spread of infection.
A facility failed to provide a communication board for a non-English speaking resident, impacting their ability to communicate effectively with staff. The resident, who preferred speaking Spanish, had no communication board in their room, contrary to facility policy. This oversight had the potential to affect the resident's care and quality of life.
A resident with a history of falls and multiple medical conditions was at risk due to the facility's failure to maintain their bed in the lowest position, as required by their care plan. Observations confirmed the bed was not adjusted properly, despite the resident's medium fall risk and the facility's fall management policy.
A facility failed to label the nasal cannula (NC) tubing for a resident, which could lead to infection. The resident, with acute respiratory failure and dysphagia, was on continuous oxygen via NC. The NC was not dated or labeled, contrary to the facility's policy requiring weekly changes. The Infection Preventionist Nurse confirmed the labeling requirement to prevent bacterial accumulation.
A facility failed to act on a pharmacist's medication regimen review (MRR) recommendation for a resident prescribed PRN Ondansetron. The MRR suggested specifying the therapy length, but no action was taken until the medication was discontinued months later. Interviews revealed the facility did not notify the prescribing physician or update the order, missing the opportunity to prevent unnecessary medication use.
A facility failed to document a specific indication for the use of Mirtazapine for a resident with major depressive disorder, as required by its policy on psychotropic medications. The resident's physician order cited mood, sleep, and appetite stimulant as reasons for the medication, but these were not considered specific manifestations by the DON. This lack of documentation could lead to unnecessary psychotropic drug use.
A facility failed to keep an electric fan in a safe and sanitary condition for a resident with severe cognitive impairment and health issues like CHF and asthma. The fan was dusty and covered with lint, which was noted by a CNA as potentially harmful. The DON stated that housekeeping should ensure personal equipment is clean, as per the facility's housekeeping policy.
The facility failed to accurately post the actual number of nursing staff on duty, leading to discrepancies in staffing information available to residents and family members. The Director of Staff Development acknowledged the inaccuracies, which could mislead residents and family members about staffing levels.
A resident with multiple health conditions, including edentulous status, did not have a timely care plan developed for their dental needs. The facility failed to adhere to its policy requiring a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of MDS completion. This delay in care planning was acknowledged by staff and had the potential to impact the resident's health.
A resident with diabetes and dementia experienced a delay in podiatric care due to the facility's failure to arrange a timely consult with a podiatrist. Despite a care plan indicating the need for foot care, the consult was delayed by three months, leading to untreated foot issues. Staff interviews confirmed the oversight, acknowledging the risk of complications due to the resident's condition.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, resulting in a deficiency. Resident 138, who was admitted with diabetes mellitus and generalized muscle weakness, was found exposed from above the knee to the chest area while lying in bed. The privacy curtain was not closed, allowing the resident's body to be visible from the hallway. This occurred after a Certified Nursing Assistant (CNA) prepared the resident for a bed bath and forgot to close the privacy curtain, which is a necessary step to ensure the resident's privacy and dignity. Similarly, Resident 238, admitted with a fracture of the right femur, experienced a breach of privacy when a Minimum Data Set Nurse (MDSN) checked the resident's surgical site without closing the privacy curtain. This action exposed the resident's thigh, compromising their privacy. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's dignity. The facility's policy and procedure on resident rights emphasize the importance of maintaining privacy during examinations and treatments by using closed doors or drawn curtains.
Failure to Ensure Call Light Accessibility and Understanding
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of four residents, specifically regarding the accessibility and understanding of the call light system. For Residents 13, 20, and 57, the call light was not within reach, which is crucial for residents to request assistance from the nursing staff. Resident 13, who had severe cognitive impairment and was at risk for falls, had their call light on the floor, making it inaccessible. Similarly, Resident 20, who was assessed as high risk for falls, could not reach their call light as it was hanging on an oxygen concentrator three feet away. Resident 57, with severely impaired cognition, had their call light tangled on the bed rail, rendering it unusable. Resident 39, who had moderately impaired cognition and was at high risk for falls, did not know how to use the call light, and its purpose was not explained to them. This lack of instruction left Resident 39 without a reliable means to communicate with staff, as they resorted to shouting for help. The facility's policy requires that the call light be within reach and that its use be explained to residents, but this was not adhered to in Resident 39's case. Interviews with staff, including the Director of Nursing and the Director of Staff and Development, confirmed that the call lights should be within reach and that residents should be instructed on their use. The facility's policy and procedure on call lights emphasize the importance of providing residents with a means of communication with the nursing staff, which was not consistently implemented, leading to the deficiencies observed.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide necessary care and services for residents with indwelling catheters, as observed in four residents. Resident 19's Foley catheter tubing was not secured and had visible white sediments, which were not monitored as required. The resident's care plan indicated the need for a catheter stabilizer and monitoring of urine characteristics every shift, but these interventions were not followed, placing the resident at risk for urinary tract infections. Resident 26 had a suprapubic catheter that was not secured, and the site dressing was wet and unclean. The care plan required securing the catheter to prevent kinking and accidental removal, and the dressing was to be changed daily. However, during observation, the catheter tubing was found under the resident's leg, and the dressing was not maintained as per the facility's policy, increasing the risk of infection and skin irritation. Resident 32's nephrostomy tubes were not covered with a privacy bag and were positioned higher than the bladder, contrary to the care plan's instructions to position the bags lower to prevent backflow and infection. Resident 78's Foley catheter tubing had white sediments, which were not reported to the medical doctor as required. The facility's policies on catheter care and management were not adhered to, leading to potential risks of infection for the residents involved.
Failure to Implement Bedrail and Grab Bar Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of bedrails and grab bars for two residents, leading to deficiencies in care. For Resident 51, who was admitted with a displaced fracture and dislocation, the facility did not document any attempts to use appropriate alternatives before installing grab bars. The resident, who had moderately impaired cognition, was unaware of the reason for the grab bars, indicating a lack of informed consent and understanding of the risks and benefits associated with their use. Similarly, for Resident 33, who had diagnoses including hemiplegia and neuropathy, the facility installed bedrails without attempting alternative interventions or obtaining informed consent. The resident, who had intact cognition, was not informed about the bedrails and did not request them. The facility's Director of Nursing acknowledged that alternatives should have been attempted and consent obtained before installation. The facility's policy required an interdisciplinary team assessment and informed consent prior to the use of bedrails, which was not followed in these cases.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring that staff wore the required personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). In one instance, a Certified Nurse Assistant (CNA 2) provided care to a resident with an indwelling catheter without wearing a gown, only using gloves. This resident was on EBP due to the presence of a Foley catheter, which required the use of gown and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Another incident involved a Licensed Vocational Nurse (LVN 4) who entered a resident's room without donning the required PPE before checking the resident's gastrostomy tube (G-tube) placement for medication administration. The resident was on EBP due to the presence of a G-tube, and the facility's policy required staff to wear gown and gloves during such care activities to prevent the transmission of infections. Additionally, a Certified Nurse Assistant (CNA 6) entered a resident's room to provide a bed bath without wearing a gown, despite signage indicating the need for PPE due to the resident being on EBP for an open wound. The facility's policy mandated the use of gown and gloves during high-contact care activities, such as bathing and providing hygiene, to protect both residents and staff from infection. These failures in adhering to the facility's infection control policies had the potential to result in the spread of infection and cross-contamination.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an effective communication method for a non-English speaking resident, identified as Resident 138, which had the potential to impact the resident's ability to receive necessary care and services. Resident 138 was admitted with diagnoses including diabetes mellitus and generalized muscle weakness. The resident's Minimum Data Set (MDS) indicated that they had clear speech, intact cognition, and a preference for speaking Spanish. However, during an observation and interview, it was noted that Resident 138 was unable to communicate in English, and there was no communication board present in the resident's room to facilitate communication with non-Spanish speaking staff. The Minimum Data Set Coordinator (MDSC) and the Social Service Director (SSD) both acknowledged the absence of a communication board, which was against the facility's policy for non-English speaking residents. The facility's policy required that a communication board with universally known drawings be provided to residents who do not speak English to ensure effective communication and meet the resident's needs. The lack of a communication board in Resident 138's room was a failure to adhere to this policy, potentially affecting the resident's quality of life and care.
Failure to Maintain Bed in Lowest Position for Fall Risk Resident
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for a resident, identified as Resident 40, by not ensuring that the resident's bed was in the lowest position. This oversight was observed during multiple visits to the resident's room, where the bed was found to be 25 to 26 inches from the top of the mattress to the floor, contrary to the care plan's directive for fall reduction measures. The resident, who has a history of falls and multiple medical conditions including Parkinson's disease and arthritis, was assessed as being at medium risk for falls. The resident's care plan, initiated on July 29, 2024, specifically indicated that the bed should be adjusted to the lowest position to mitigate fall risks. Despite this, observations on January 7 and January 8, 2025, confirmed that the bed was not in compliance with the care plan. Interviews with the resident and a Certified Nursing Assistant (CNA) further highlighted the resident's need for assistance with transfers and the importance of maintaining the bed in the lowest position to prevent falls. The facility's policy on fall management, revised in June 2020, mandates an environment as free of accident hazards as possible, which was not adhered to in this instance.
Failure to Label Nasal Cannula Tubing
Penalty
Summary
The facility failed to label the nasal cannula (NC) tubing for a resident, identified as Resident 64, which had the potential to result in infection. Resident 64 was admitted with acute respiratory failure and dysphagia and was dependent on others for certain activities. The resident's Minimum Data Set (MDS) indicated clear speech and the ability to understand and communicate. The Order Summary Report (OSR) for January 2025 showed an order for continuous oxygen via NC at 2 liters per minute every shift. During an observation, it was noted that the NC was not dated or labeled with the application date. The Infection Preventionist Nurse (IPN) confirmed that the NC should be labeled with the date of application and changed weekly to prevent bacterial accumulation. The facility's policy on Oxygen Therapy, dated January 2024, required oxygen tubing to be replaced every 7 days.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act upon the consultant pharmacist's medication regimen review (MRR) recommendation for a resident, identified as Resident 40. The MRR, conducted between August 1, 2024, and August 26, 2024, suggested specifying the length of therapy for the resident's PRN Ondansetron prescription, which is typically used for short-term nausea and vomiting. However, there was no documentation or change in the physician's order regarding this recommendation until the medication was discontinued on December 3, 2024. Interviews with the registered nurse and the Director of Nursing revealed that the facility did not notify the prescribing physician or update the order based on the pharmacist's recommendation, which was acknowledged as a missed action. Resident 40 was readmitted to the facility with diagnoses including depression disorder and hypertension. The resident's Minimum Data Set indicated they had clear speech, could understand others, and required assistance with personal hygiene and dressing. Despite the pharmacist's recommendation, the facility did not act within the stipulated time frame of seven days as per their policy and procedure, potentially exposing the resident to unnecessary medication and adverse health consequences. The Director of Nursing confirmed that the MRR should have been addressed promptly to prevent such risks.
Failure to Document Specific Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document a specific indication for the use of Mirtazapine, an antidepressant, for Resident 20, as required by the facility's policy on psychotropic medications. Resident 20 was admitted with diagnoses including spondylolisthesis and major depressive disorder. The Minimum Data Set (MDS) indicated that Resident 20 had intact cognition for daily decision-making and required supervision during showers. The physician's order for Mirtazapine was related to major depressive disorder, manifested by mood, sleep, and appetite stimulant, but these were not considered specific manifestations or behaviors by the Director of Nurses (DON). During an interview and record review, the DON acknowledged that the medication needed to be administered with a specific diagnosis and symptoms, which were not adequately documented. The facility's policy stated that psychotropic medications should not be used for discipline or convenience and should only be administered to treat the resident's medical symptoms. The lack of specific documentation for the use of Mirtazapine had the potential to result in unnecessary psychotropic drug use, which could lead to significant adverse consequences for Resident 20.
Failure to Maintain Sanitary Conditions for Resident's Equipment
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident with severe cognitive impairment and multiple health conditions, including congestive heart failure and asthma. The fan, located at the resident's bedside, was observed to be dusty and covered with lint, which was acknowledged by a Certified Nurse Assistant as potentially harmful to the resident's health. This observation was made during a room inspection and interview with the CNA. The Director of Nursing confirmed that housekeeping staff are responsible for ensuring that residents' personal equipment is kept clean and in good working condition. The facility's policy and procedure for the housekeeping department, revised in 2007, mandates effective environmental sanitation to reduce exposure to contaminated air, dust, and equipment. The policy emphasizes frequent cleaning to remove microorganisms that could pose health hazards, with the housekeeping supervisor collaborating with the infection control team to maintain high cleanliness standards.
Inaccurate Posting of Nursing Staff Numbers
Penalty
Summary
The facility failed to accurately post the actual number of nursing staff who worked on specific dates, leading to discrepancies in the staffing information available to residents and family members. On January 1, 2025, during the night shift, five CNAs worked instead of the six that were posted. On January 2, 2025, during the morning shift, 16 CNAs worked instead of the 14 that were posted. On January 3, 2025, during the morning shift, 13 CNAs worked instead of the 14 that were posted. On January 5, 2025, during the night shift, seven CNAs worked instead of the six that were posted. The Director of Staff Development acknowledged that the staffing information was not accurate, which could mislead residents and family members about the actual staffing levels. The facility's policy and procedure required the posting of accurate staffing numbers for those directly responsible for resident care.
Failure to Develop Timely Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's oral/dental status, which was necessary due to the resident's edentulous condition. The resident, who was admitted with diagnoses including a cerebral vascular accident, type 2 diabetes, and dementia, required assistance with eating and oral hygiene. Despite these needs, the facility did not create a care plan for the resident's dental condition until several months after admission, which was not in compliance with the facility's policy. Interviews with the Assistant Director of Nursing/MDS Nurse and a Registered Nurse revealed that the care plan for the resident's dental condition was not initiated until months after admission, and a dental consult was delayed. The facility's policy required a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of the MDS completion, which was not adhered to in this case. This oversight had the potential to impact the resident's health, as noted by the staff, who acknowledged the risk of weight loss due to the lack of a timely care plan.
Delay in Podiatric Care for Diabetic Resident
Penalty
Summary
The facility failed to ensure timely podiatric care for a resident, leading to a delay in necessary foot treatment. The resident, who was admitted with a history of a cerebral vascular accident, type 2 diabetes, and dementia, had a care plan dated 8/11/24 that included a referral to a podiatrist for foot care. However, the consult was not arranged until 11/14/2024, three months later. This delay in implementing the care plan resulted in the resident not receiving timely foot care, which could lead to podiatric complications due to their diabetes. Interviews with the Assistant Director of Nursing and a Registered Nurse confirmed that the care plan for podiatric consultation was not followed through in a timely manner. The facility's policy indicated that residents should receive podiatry services every 60 days or as needed, especially for those with diabetes and circulatory disorders. The resident's podiatry visit note from 11/14/2024 indicated significant foot issues, including dystrophic toenails and fungal infection, which were addressed during the visit. The delay in care was acknowledged by the staff, who recognized the risk of further injury due to the resident's diabetic condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baldwin Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Covina Healthcare Center | 0.6 mi | — | 16 | 0 |
| Victoria Care Center | 0.8 mi | — | 13 | 0 |
| Beacon Healthcare Center | 1.1 mi | — | 6 | 0 |
| West Haven Healthcare | 1.1 mi | — | 16 | 0 |
| West Covina Medical Center D/p Snf | 1.2 mi | — | 15 | 0 |
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