Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 San Marino Healthcare Center during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of anxiety and injury was subjected to sexual abuse by another resident, who touched her inappropriately and exposed himself in the presence of both the resident and a CNA. The incident was witnessed and reported by staff, and both residents were documented as having the capacity to understand their actions. Facility policy requiring protection from abuse was not upheld, resulting in a violation of resident rights.
A sexual abuse incident occurred when a resident inappropriately touched and exposed himself to another resident in the presence of a CNA. Although the CNA promptly informed the CN, the required notifications to the SSA, Ombudsman, and local law enforcement were not made within the mandated two-hour timeframe, resulting in a delay of over two hours before authorities were contacted.
A resident's privacy was violated when another resident entered a common restroom without a lock or signage, leading to a breach of privacy and dignity. The facility's policies on resident rights and dignity were not followed, as confirmed by staff interviews.
A resident was prescribed Risperdal without a specific target behavior indicated in the order, contrary to the facility's policy on psychotropic medication use. The resident, diagnosed with schizophrenia and other mental health disorders, exhibited aggressive behavior, but the order lacked documentation for monitoring target behaviors or adverse reactions. Facility staff confirmed the omission, highlighting the need for specific behavior documentation to ensure medication appropriateness and effectiveness.
A facility failed to ensure a resident wore a prescribed brace for a right humerus fracture as ordered. The resident, with a displaced fracture and dementia, was observed without the brace, which was found on the nightstand. Staff interviews revealed confusion about reapplying the brace, with some expressing fear of moving the resident's arm. The importance of the brace for healing and immobilization was confirmed by the RN Supervisor and OT, while the DON emphasized the need for licensed staff to reapply it after baths.
Two residents with language barriers were not provided with communication aids, hindering their ability to communicate with staff. One resident with COPD and dementia did not have a communication board, while another with multiple diagnoses faced similar challenges. Staff were unable to effectively communicate with these residents, and the facility's policies on language access were not followed, posing potential risks in emergencies.
The facility failed to ensure sanitary conditions in food storage and dish sanitization. Food items in the kitchen were not properly labeled with received or expiration dates, and some were expired. Additionally, expired chlorine test strips were used to verify dishwasher sanitization, leading to unreliable results. These deficiencies posed potential health risks to residents.
Two residents with cognitive impairments were assisted with meals by a CNA who stood over them, failing to maintain eye level, which compromised their dignity. The facility's policy requires staff to be seated at eye level during feeding to ensure resident dignity and safety.
A resident with severe cognitive impairment was administered Quetiapine Fumarate for nine days without informed consent from their responsible party, violating their right to be informed and to consent to treatment. Facility staff confirmed the absence of consent in the resident's chart, contrary to policy requirements.
The facility failed to provide accessible call devices for three residents with limited mobility and cognitive impairments. One resident with limited hand motion struggled to use the call light, while two others had call lights placed out of reach. The facility's policy requires alternate communication means for residents unable to use standard call systems, but this was not implemented.
A facility failed to inform a resident of their right to formulate an advance directive, as required by policy. The resident, who had moderate cognitive skills and required assistance with daily activities, did not have a completed Advance Directives Acknowledgement form in their chart. This oversight was confirmed by an LVN and acknowledged by the Social Services Director, indicating a lapse in the facility's admission process.
Two residents in an LTC facility experienced deficiencies in their environment and equipment. One resident's room lacked a bulb in the overhead light, posing a fall risk, while another resident's wheelchair had holes and ripped edges, and the overhead light was inaccessible. Both residents have moderate cognitive impairment and require assistance with daily activities.
A resident with depressive disorder, presbyopia, and anxiety was found to have long and dirty fingernails, despite requiring assistance with personal hygiene. The resident had been requesting help with nail care but did not receive it. Facility staff acknowledged the issue, and the resident's care plan included grooming assistance, yet the facility failed to provide the necessary services.
A resident's room was found with an unattended open A&D ointment on the bedside table, posing a potential ingestion risk. The resident, with intact cognitive skills and no self-administration order, was observed in this condition. Staff confirmed the oversight, and the DON acknowledged the risk, highlighting a lapse in the facility's safety policies.
The facility failed to maintain accurate COVID-19 vaccination records for four staff members, including the IPN and DON, as required by policy. The Employee COVID-19 Vaccination log was not updated, which was confirmed during interviews and record reviews. This deficiency was noted as the facility's policy required maintaining a current tracking worksheet of staff vaccination status.
The facility failed to post accurate Daily Staffing Reports, with discrepancies noted on several dates between the reported and actual number of CNAs responsible for resident care. Interviews with the DSD and DON emphasized the importance of accurate staffing data to ensure compliance with NHPPD regulations and adequate staff coverage. The facility's policy requires daily posting of staffing data, but this was not consistently followed.
A facility failed to implement a resident-centered fall prevention plan for a high-risk resident with cognitive impairments and physical limitations. Despite identified fall risk factors, the care plan lacked specific interventions, focusing instead on post-fall measures. Staff interviews confirmed the need for supervision and assistance, highlighting the care plan's inadequacy in addressing the resident's needs.
A resident with severe cognitive impairment reported being hit by a male nurse, but the LTC facility failed to report the allegation to CDPH, the state ombudsman, and law enforcement as required by their policy. Despite staff awareness of the reporting requirements, the incident was not communicated to the necessary authorities, highlighting a deficiency in following the facility's abuse reporting procedures.
A resident with severe cognitive impairment alleged being hit by a male nurse, but the LTC facility failed to conduct a thorough investigation or report the findings to the State Survey Agency. Despite the report being made to staff, no interdisciplinary team meeting was held, and there was no documentation of an investigation into male staff members present at the time. This was contrary to the facility's abuse prevention and reporting policies.
A resident with a history of elopement and mental health issues left an LTC facility through a broken window without staff knowledge. Despite being identified as high risk for elopement, the resident's care plan interventions, including hourly head counts, were not effectively implemented. The facility's staff discovered the resident missing after a CNA returned from a lunch break, and the window was found inadequately secured. The resident remains missing.
The facility failed to provide adequate supervision to prevent a resident from eloping and did not ensure staff competency during a fire alarm. The resident, with severe cognitive impairments, exited through an unsupervised and unlocked gate during a fire alarm. Staff did not conduct required head counts or monitor exit doors properly, leading to the resident being found disoriented hours later by emergency services.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
A deficiency occurred when a resident was subjected to sexual abuse by another resident in the facility. The incident took place in the early morning hours when one resident, while waiting for medication at the nursing station, was approached by another resident in a wheelchair. The second resident touched the first resident inappropriately on the buttocks and subsequently exposed his genitalia to both the resident and a Certified Nursing Assistant (CNA) who was present at the scene. The CNA immediately confronted the perpetrator, informing him that such behavior was not allowed. The incident was witnessed by the CNA, who reported it to the Charge Nurse. Documentation and interviews confirm that the inappropriate touching and exposure were observed and that the events were communicated to facility leadership, including the Director of Nursing (DON) and Registered Nurse Supervisor (RN Sup 1). The victim provided a written statement detailing the sequence of events, including the physical contact and exposure, and described the emotional impact of the incident. The facility's records indicate that both residents involved had the mental capacity to understand and make decisions at the time of the incident. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse by anyone, was not upheld in this instance. The failure to prevent the sexual abuse resulted in a violation of the resident's rights and had the potential to cause negative psychosocial outcomes. The report documents the sequence of events and the immediate actions taken by staff who witnessed the incident, but does not include any corrective or follow-up actions taken by the facility after the event.
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving two residents within the required two-hour timeframe to the State Survey Agency (SSA), Ombudsman, and local law enforcement. The incident occurred when one resident, while in a wheelchair, inappropriately touched another resident's buttocks and subsequently exposed his genitalia in the presence of the victim and a Certified Nurse Assistant (CNA). The CNA immediately informed the Charge Nurse (CN) of the incident, but the required notifications to authorities were not made until more than two hours after the event. Resident 1, who was the victim, had a medical history including an unspecified injury, open wound to the right knee, anxiety disorder, and effusion of the right ankle, and was determined to have the capacity to understand and make decisions. Resident 2, the perpetrator, had diagnoses of dysphagia, schizophrenia, acquired absence of the left leg above the knee, and anxiety disorder, and also had the capacity to make medical decisions. The incident was witnessed by CNA1, who reported it to the CN, but there was a delay in escalating the report to the appropriate authorities as required by facility policy and state regulations. Interviews with facility staff, including the Director of Nursing (DON), Registered Nurse Supervisor (RN Sup 1), Administrator, CN, and CNA1, confirmed that the incident was not reported within the mandated two-hour window. Facility policy clearly states that all allegations of abuse must be reported immediately, defined as within two hours, to the SSA, Ombudsman, and law enforcement. The delay in reporting was acknowledged by staff during interviews, and documentation confirmed that the notifications were made approximately two and a half hours after the incident occurred.
Privacy Violation in Restroom Use
Penalty
Summary
The facility failed to protect the privacy of a resident while using the restroom, which is a violation of the resident's rights to privacy and dignity. On 2/28/2025, Resident 1, who has schizoaffective disorder and requires substantial assistance with personal care, was using a common restroom when another resident, Resident 2, entered and asked Resident 1 to leave so they could take a shower. The restroom did not have a lock or signage to indicate it was in use, leading to the privacy breach. Interviews with staff, including a CNA, LVN, and the Director of Nursing, confirmed that the facility did not ensure the privacy and dignity of Resident 1. The facility's policies on resident rights and dignity emphasize the importance of protecting residents' privacy, but these were not adhered to in this instance. The lack of proper restroom facilities contributed to the violation of Resident 1's rights, as there was no way to signal that the restroom was occupied.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Risperdal, as per the facility's policy and procedure on psychotropic medication use. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and anxiety disorder, was prescribed Risperdal without a specific target behavior indicated in the physician's order. This omission was identified during a review of the resident's records and confirmed through interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Interim Director of Nursing (DON). The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and the presence of mood symptoms, and the resident was observed to have received antipsychotic medication routinely. However, the order for Risperdal lacked documentation of a specific target behavior, such as sudden striking or hitting another resident, which was necessary to justify the medication's use. Additionally, there was no order to monitor or document the occurrence of target behaviors or any adverse reactions to the medication, which are critical components of ensuring the medication's appropriateness and effectiveness. Interviews with facility staff revealed that the resident had exhibited physically aggressive behavior, such as punching another resident, which was not documented in the Risperdal order. The staff acknowledged the importance of including specific target behaviors in medication orders to guide monitoring and assess the medication's effectiveness. The facility's policy requires that psychotropic medications be prescribed based on a comprehensive review of the resident's condition, including monitoring for adverse consequences, which was not adhered to in this case.
Failure to Ensure Resident Wore Prescribed Brace
Penalty
Summary
The facility failed to ensure that a resident wore a prescribed brace for a right humerus fracture as ordered by the physician and outlined in the care plan. The resident, who was admitted with a displaced fracture of the right humerus and dementia, was observed without the brace, which was found on the nightstand. The care plan and physician's orders specified that the brace should be worn at all times, except during sponge baths, to prevent dislocation and aid in healing. Interviews with staff revealed a lack of clarity and responsibility regarding the reapplication of the brace. A Restorative Nurse Assistant was unaware of when or why the brace was removed, while a Licensed Vocational Nurse expressed fear of moving the resident's fractured arm. The Registered Nurse Supervisor and Occupational Therapist confirmed the importance of the brace for immobilization and healing, and the Director of Nursing emphasized the need for licensed staff to reapply the brace after baths. The facility's policies on splinting and assistive devices were reviewed, highlighting the importance of maintaining range of motion and ensuring safety.
Failure to Provide Communication Aids for Residents with Language Barriers
Penalty
Summary
The facility failed to provide appropriate communication aids for residents with language barriers, which hindered their ability to communicate effectively with staff. Resident 24, who was admitted with chronic obstructive pulmonary disease and dementia, had a care plan indicating the need for communication devices due to a language barrier. However, during observations, it was noted that Resident 24 did not have a communication board at their bedside, and staff were unable to communicate with the resident effectively. Interviews with the Director of Nursing and a Registered Nurse confirmed that a communication board should have been available, but it was not found in the designated areas. Similarly, Resident 28, who had multiple diagnoses including polyneuropathies, COPD, and schizophrenia, also faced communication challenges due to a language barrier. The resident's preferred language was not accurately reflected in the admission records, and there was no communication board or aid available at the bedside. Observations showed that Resident 28 struggled to communicate with staff, leading to misunderstandings about the resident's needs. Staff confirmed the absence of communication aids and expressed difficulty in understanding the resident's requests. The facility's policies on translation and accommodation of needs were not adhered to, as staff were not adequately trained to provide language access services. The lack of communication aids and training posed a potential risk to residents in emergencies, as staff could not effectively communicate with residents who spoke different languages. The facility's failure to implement its policies resulted in residents being unable to communicate their needs, potentially delaying necessary care and treatment.
Deficiencies in Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage, preparation, and distribution of food, as observed during a survey. In the kitchen's produce refrigerator and dry storage area, food items were found without labels indicating the received or expiration dates. Some items, such as Parmesan cheese and ground pork, were past their use-by dates, and other items like cups filled with red liquid and milk lacked serve-by dates. The Dietary staff confirmed the absence of proper labeling and acknowledged the risk of residents consuming expired food, which could lead to illness. Additionally, the facility did not ensure the proper sanitization of dishware due to the use of expired chlorine test paper strips. The Dishwashing Staff and Dietary Staff Supervisor confirmed that the test strips used to verify the dishwasher's sanitization were expired, rendering the test results unreliable. This oversight could result in cross-contamination, as the dishwasher might not effectively sanitize the dishes. The facility's policies and procedures require all food to be labeled with dates and the dishwasher to be properly sanitized, but these were not adhered to, leading to potential health risks for the residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents during meal assistance. Resident 37, who was admitted with generalized muscle weakness and polyneuropathy, was observed being assisted with eating by a CNA who stood over the resident, not maintaining eye level, and used a towel as a clothing protector. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with eating. Similarly, Resident 42, diagnosed with major depressive disorder and dementia, was also assisted by the same CNA who stood over the resident while feeding. The MDS for Resident 42 showed severe cognitive impairment and a requirement for partial assistance with eating. Interviews with staff, including an LVN and the DON, confirmed that staff should be seated at eye level with residents during feeding to ensure dignity and safety, as per the facility's policy revised in July 2017.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility's licensed staff failed to obtain informed consent from the responsible party of a resident before administering Quetiapine Fumarate, an antipsychotic medication. This deficiency was identified during a survey involving observation, interviews, and record reviews. The resident in question was admitted with diagnoses including schizophrenia, anxiety, and dementia, and was noted to be severely impaired in cognitive skills for daily decision-making. Despite this, the resident was administered Quetiapine Fumarate for nine days without the necessary informed consent, violating the resident's right to be fully informed and to consent to receive psychoactive medications. The facility's policy and procedure documents, as well as federal and state laws, require that residents be informed of their medical condition and treatment options, and that informed consent be obtained prior to administering any medication or treatment. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the informed consent was not present in the resident's chart, and that the medication was administered without authorization. This oversight highlights a failure to adhere to established protocols for informed consent, as outlined in the facility's policies.
Deficiency in Call Device Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of three residents, resulting in deficiencies related to the accessibility of call devices. Resident 37, who had limited range of motion in both hands due to generalized muscle weakness and polyneuropathy, was not provided with an appropriate call device. Despite being dependent on assistance for various daily activities, Resident 37's call light cord was placed on top of the bed, making it difficult for the resident to use. During an observation, the resident struggled to pull the call light cord and expressed frustration, indicating that he often resorted to yelling for help. A registered nurse confirmed that Resident 37 would not be able to pull the cord due to contracted hands and suggested that a touch-activated call light would be more suitable. Similarly, Resident 45, who had muscle wasting and metabolic encephalopathy, was observed with a call light mounted to the wall, with the cord wrapped around the base, approximately seven feet away from the resident. This placement rendered the call light inaccessible to Resident 45, who required partial assistance with daily activities. A registered nurse acknowledged that the resident would not be able to reach the call light in its current position. Resident 208, diagnosed with muscle wasting, atrophy, and lack of coordination, also faced issues with call light accessibility. The call light in Resident 208's room was attached to the wall, about seven feet away, with only a short metal string attached, making it impossible for the resident to reach. The resident confirmed the inability to reach the call light to request help. The facility's policy indicated that residents should be provided with a means to call staff for assistance, and if a disability prevents the use of the call system, an alternate means should be documented in the care plan. However, this was not adhered to for the residents in question.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to adhere to its policy regarding advance directives for one of the four sampled residents, identified as Resident 208. Upon review, it was found that the facility did not provide Resident 208 with written information about the option to formulate an advance directive. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN 1), who acknowledged that the Advance Directives Acknowledgement form in Resident 208's chart was blank. The resident was admitted with diagnoses including muscle wasting, atrophy, and lack of coordination, and had moderate cognitive skills for daily decision-making, requiring varying levels of assistance with daily activities. The Social Services Director (SSD) stated that the facility's procedure is to complete the Advance Directives Acknowledgement form upon admission or as soon as possible, to ensure residents are aware of their rights to formulate an advance directive. However, in this case, the form was not completed, leaving Resident 208 uninformed of their rights and potentially impacting the staff's ability to carry out the resident's healthcare wishes in an emergency. This deficiency highlights a lapse in the facility's process for ensuring residents are informed about their healthcare rights and options.
Deficiencies in Resident Environment and Equipment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents, as required by its policy. Resident 45's room was observed to have an overhead light without a bulb, which could pose a risk for falls and injuries in the dark. The resident, who has moderate cognitive impairment and requires assistance with various daily activities, was at risk due to the lack of adequate lighting. Resident 208's wheelchair was found to have multiple holes and ripped edges on the seat, making it uncomfortable and potentially hazardous for the resident's skin. Additionally, the overhead light in Resident 208's room was not accessible due to a short metal string, preventing the resident from turning it on. This resident also has moderate cognitive impairment and requires substantial assistance with daily activities, including the use of a wheelchair. The facility's policies emphasize the importance of providing a safe, clean, and comfortable environment with adequate lighting to promote safety and independence. However, the observations and interviews revealed that these policies were not followed, leading to deficiencies in the care and environment provided to Residents 45 and 208.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who was unable to perform activities of daily living independently. Resident 8, who was admitted to the facility with diagnoses including depressive disorder, presbyopia, and anxiety, was observed to have long and dirty fingernails. Despite having the capacity to understand and make decisions, Resident 8 required substantial maximal assistance with personal hygiene. During observations and interviews, it was noted that the resident's fingernails were not trimmed and were dirty, with debris under the nails. The resident expressed that they had been requesting nail clippers for a long time but had not received assistance. The facility's staff, including LVN 3 and LVN 4, acknowledged the condition of the resident's fingernails and the importance of keeping them clean and trimmed to prevent potential harm and bacterial harboring. The resident's care plan indicated the need for assistance with grooming and fingernail trimming, yet this was not being followed. The Director of Nursing also emphasized the importance of maintaining good hygiene to prevent infection. The facility's policies and procedures stated that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and hygiene, which was not adhered to in this case.
Failure to Maintain Accident-Free Environment
Penalty
Summary
The facility failed to maintain an accident-free environment for a resident by leaving an open A&D ointment on the resident's bedside table. This ointment, used as a moisturizer for skin irritations, was observed unattended in the resident's room. The resident, admitted with diagnoses including depressive disorder, presbyopia, and anxiety, was noted to have intact cognitive skills for daily decision-making and was independent with eating but required assistance with personal hygiene. Despite the resident's capacity to understand and make decisions, there was no order on the resident's chart indicating permission to self-administer medication. During observations and interviews, it was confirmed by a CNA and an LVN that the ointment was left unattended, which could pose a risk if ingested by wandering residents. The facility's Director of Nursing acknowledged that leaving open medication at the bedside was unacceptable, especially in a setting with residents who might have serious mental illnesses. The facility's policies emphasized maintaining a safe environment and preventing accidents, yet this incident demonstrated a lapse in adhering to these policies.
Failure to Maintain Accurate COVID-19 Vaccination Records for Staff
Penalty
Summary
The facility failed to maintain accurate documentation of COVID-19 vaccination status for four out of 73 staff members, as required by their policy. During an interview and record review, the Infection Prevention Nurse (IPN) confirmed that the Employee COVID-19 Vaccination log was not updated to reflect the vaccination status of herself, the Director of Staff Development, the Dietician, and one of the Activity Assistants. This oversight was acknowledged by the IPN, who stated that the log did not accurately list staff who had received the current COVID-19 vaccine. The Director of Nursing (DON) emphasized the importance of having an up-to-date vaccination log to identify staff at high risk of contracting COVID-19, especially those with co-morbidities. The DON also noted the necessity of accurate reporting to the National Healthcare Safety Network and the California Immunization Registry. The facility's policy required the IP to maintain a tracking worksheet of staff vaccination status, which was not adhered to, leading to the deficiency.
Inaccurate Daily Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Daily Staffing Report, which is required to be posted daily in accordance with the facility's policy and procedure. On 11/11/2024, the Daily Staffing Report was not posted, and on multiple dates, including 11/8/2024, 11/11/2024, 11/12/2024, and 11/13/2024, the report did not accurately reflect the total number and actual hours of certified nursing assistants (CNAs) responsible for resident care. These discrepancies were identified through observation, interviews, and record reviews, revealing that the posted reports did not match the actual staffing levels as indicated by the Facility Staffing Assignment and Sign-In Sheets. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) highlighted the importance of accurate staffing reports to ensure adequate staff coverage and compliance with Nursing Hours Per Patient Day (NHPPD) regulations. The DSD acknowledged the inaccuracies and the potential impact on the quality of care if the facility had fewer CNAs than reported. The facility's policy, revised in August 2022, mandates that staffing data be posted within two hours of each shift's start, in a prominent location, and in a clear format. However, the facility failed to adhere to this policy, resulting in the potential for residents and visitors to be uninformed about the facility's staffing levels.
Failure to Implement Resident-Centered Fall Prevention Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered fall care plan for a resident, identified as Resident 1, who was at high risk for falls. The resident was admitted with multiple diagnoses, including lack of coordination, muscle wasting, generalized muscle weakness, and dementia, which contributed to their fall risk. The Minimum Data Set (MDS) assessment indicated that the resident required substantial assistance with various activities, including walking, toileting, and dressing, due to severely impaired cognitive skills and fluctuating decision-making capacity. The facility's fall risk evaluation identified several risk factors for Resident 1, including disorientation, incontinence, orthostatic hypotension, predisposing diseases, multiple medications, balance problems, and decreased muscular coordination. Despite these identified risks, the care plan did not include specific interventions tailored to the resident's needs, such as supervision during ambulation and assistance with transfers. Interviews with facility staff, including the Director of Rehab, MDS Nurse, and Licensed Vocational Nurse, confirmed that the resident required supervision and assistance due to their unsteady gait and cognitive impairments. The facility's policy and procedure for managing falls and fall risks emphasized the need for resident-centered interventions to address specific risk factors. However, the care plan for Resident 1 primarily focused on post-fall interventions rather than preventive measures. The Director of Nursing acknowledged that the care plan was inadequate and did not align with the facility's policy, which required comprehensive, person-centered care plans with measurable objectives and timeframes to meet residents' needs.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the appropriate authorities, including the California Department of Public Health (CDPH), the state ombudsman, and local law enforcement. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses of encephalopathy and Alzheimer's disease, reported to a family representative that he was hit by a male nurse. Despite the report being made to the Director of Nursing (DON), the allegation was not communicated to the required external agencies as per the facility's policy. The resident's cognitive impairments, as documented in the Minimum Data Set, indicated severe impairment in decision-making and required substantial assistance with daily activities. The incident was initially reported by the resident's family representative to a Licensed Vocational Nurse (LVN), who then informed the DON. However, the DON acknowledged that the allegation was not reported to CDPH, the state ombudsman, or law enforcement, which is a requirement under the facility's policy for handling abuse allegations. Interviews with various staff members, including LVNs and a Certified Nursing Assistant (CNA), confirmed that the facility's policy mandates immediate reporting of abuse allegations to the relevant authorities within two hours. The facility's policy, titled 'Abuse Investigation and Reporting,' outlines the procedure for reporting such incidents, emphasizing the need for prompt communication with local, state, and federal agencies. Despite this, the facility did not adhere to its policy, resulting in a failure to report the abuse allegation involving the resident.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting in the case of a resident who alleged physical abuse by a male nurse. The resident, who was admitted with diagnoses of encephalopathy and Alzheimer's disease, reported to his family representative that he was hit by a male nurse. Despite the resident's severe cognitive impairment and fluctuating capacity to understand and make decisions, the facility did not conduct a thorough investigation into the allegation. Interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant (CNA) revealed that the allegation was reported to the facility staff, but no interdisciplinary team meeting was conducted to address the incident. The DON admitted that there was no documentation or investigation into the male staff members working on the day of the alleged incident. The facility's policy required such incidents to be promptly reported and thoroughly investigated, but this was not followed. Additionally, the facility failed to provide a written report of the investigation findings to the State Survey Agency within the required five working days. The Administrator acknowledged that an investigative report was not completed, and there was no documentation indicating that the facility had investigated the possible involvement of male staff members. This lack of action and documentation was contrary to the facility's policies and procedures for abuse prevention and reporting.
Resident Elopement Due to Inadequate Supervision and Facility Security
Penalty
Summary
The facility failed to adequately supervise and ensure the safety of a resident who was at high risk for elopement. The resident, who had a history of elopement and was diagnosed with encephalopathy and schizoaffective disorder, bipolar type, left the facility through a broken window without staff knowledge. The resident's care plan indicated a high risk for elopement, requiring hourly head counts and frequent visual checks, but these measures were not effectively implemented. On the day of the incident, the resident was last seen by a CNA at 11:00 AM in their room. The CNA went on a lunch break, and upon returning at 12:10 PM, discovered the resident missing and the window broken. The facility's staff, including an LVN and the DON, conducted a search within the facility and the surrounding area but were unable to locate the resident. The window in the resident's room was found to be inadequately secured, with a gap at the top, which may have facilitated the resident's escape. Interviews with facility staff revealed that the standard procedure of hourly head counts was not sufficient for this high-risk resident, as acknowledged by the DON. The facility's policies on emergency procedures for missing residents and elopement risk management were not effectively followed, contributing to the resident's unsupervised departure. As of the last update, the resident had not been found.
Failure to Prevent Resident Elopement and Ensure Staff Competency During Fire Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as low risk for elopement. On the day of the incident, the facility exit doors were not supervised, and a gate was left open, allowing the resident to elope. The resident, who had severe cognitive impairments and a history of dementia, schizoaffective disorder, and epilepsy, was found wandering and disoriented several hours later by emergency services. The facility's head count and call light check logs were incomplete, and staff failed to report the resident missing promptly. The incident was exacerbated by a fire alarm that was pulled by another resident, causing the exit doors to unlock temporarily. During this time, the Maintenance Supervisor left the gate open while retrieving a key to reset the alarm. Surveillance footage confirmed that the resident exited the facility through the back door and gate during this period. Interviews with staff revealed that routine checks and head counts were not conducted as required, and there was a lack of immediate action to account for all residents when the fire alarm was activated. Additionally, the facility failed to ensure that staff, specifically a Certified Nursing Assistant, had the necessary competency to manage residents during a fire alarm. Despite receiving in-service training on elopement prevention and safety, the CNA did not follow proper procedures during the fire alarm, contributing to the resident's elopement. The Director of Nursing acknowledged that staff should have been monitoring exit doors and conducting head counts more diligently, as per the facility's policies and procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,117 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Center | 0.6 mi | — | 8 | 0 |
| Huntington Drive Health And Rehabilitation Center | 1.3 mi | — | 36 | 0 |
| Baldwin Gardens Nursing Center | 1.7 mi | — | 16 | 0 |
| Pine Grove Healthcare & Wellness Centre, Lp | 1.7 mi | — | 18 | 0 |
| Santa Anita Convalescent Hospital | 1.8 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Marino Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.