14 health deficiencies
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
San Gabriel, CA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
115 Bridge St., San Gabriel, CA
(626) 289-4439
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
98
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.51
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
3,411
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.96
Baseline 24.27% · Performance 19.59% · Measure score 5.96 · Achievement 3.97 · Improvement 5.96
Healthcare-associated infections
0
Baseline 10.61% · Performance 10.60% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 23.68% · Performance 20.99% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.81
Baseline 3.74 hours · Performance 3.59 hours · Measure score 1.81 · Achievement 1.81 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 8.45% · Lower 95% interval 6.44% |
| Discharge to community | 40.17% |
50.57%
10.4 pts worse
|
Worse than the National Rate · Eligible stays 123 · Observed rate 30.89% · Lower 95% interval 30.24% |
| Medicare spending per beneficiary | 1.78 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 132 · Denominator 134 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 134 |
| Discharge self-care score | 48.75% |
53.69%
4.9 pts worse
|
Numerator 39 · Denominator 80 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 36 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 134 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 10.6% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 94 · Observed rate 18.09% · Lower 95% interval 7.38% |
| Staff COVID-19 vaccination coverage | 1.59% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 126 |
| Staff flu vaccination coverage | 19.05% |
42%
22.9 pts worse
|
Numerator 24 · Denominator 126 |
| Discharge function score | 43.75% |
56.45%
12.7 pts worse
|
Numerator 35 · Denominator 80 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 57 · Denominator 58 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44.44% |
25.2%
19.2 pts better
|
Numerator 32 · Denominator 72 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
2.3
1.6 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 4.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
1.6%
1.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.2% |
6.8%
7.4 pts worse
|
11.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 10.7% · Q3 10.7% · Q4 19.3% · 4Q avg 14.2% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
4.1%
1.1 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.9% · Q3 9.0% · Q4 4.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
13.7%
2.7 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 10.6% · Q3 10.2% · Q4 10.2% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
14.2%
8.9 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.5% · Q3 5.2% · Q4 5.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.9% |
11.0%
6.1 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 11.5% · Q3 0.0% · Q4 1.8% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
10.7%
3 pts worse
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 18.7% · Q3 13.0% · Q4 8.2% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.1% |
10.9%
8.8 pts better
|
19.8%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.6% · Q3 1.2% · Q4 1.2% · 4Q avg 2.1% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.7%
0.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.1% · Q3 8.1% · Q4 5.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
11.2%
5.8 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
23.2%
1.5 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 21.4% · Expected 23.5% · Used in QM five-star |
Survey summary
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-02
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-05-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-02
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-05-07
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-07
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-07
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-07-13
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-07-13
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-13
Fire Safety
Construct fire resistant interior walls.
Corrected 2021-07-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-07-13
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2021-07-13
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-07-13
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-13
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-13
Inspection history
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-01-19
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-02
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-02
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-02
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-02
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-02
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-02
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-05-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-07
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-28
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-07
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-07
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-07
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-05-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-07
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-07
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-05-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-07
Health
Keep all essential equipment working safely.
Corrected 2024-05-07
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-05-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-25
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-07-01
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-07-01
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-01
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-01
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-07-01
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-01
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2021-07-01
Penalties and ownership
General Partnership Interest · Organization
Operational/Managerial Control · Individual
Limited Partnership Interest · Individual
Operational/Managerial Control · Organization
Limited Partnership Interest · Individual
Operational/Managerial Control · Individual
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