San Gabriel Conv Center

F-F689

Findings:

During a review of CNA1 ' s Employee File on 3/12/25 at 11:15 am with the Director of Staff Development (DSD), indicated CNA 1 ' s date of hire was 12/23/25. A Performance Correction Notice dated 3/3/25 indicated CNA1 was reported by a Registered Nurse (RN) Supervisor on 2/27/25 about not providing necessary care to her residents assigned to CNA1, who were found completely soiled. In addition, CNA1 was reported by charge nurse that CNA1 slept throughout the shift and had to awaken CNA1 to provide care. Additionally, CNA1 was found taking longer breaks than set schedule.

During a review of CNA1 ' s Time Card for month of March 2025 and Staff Assignment Sheets, revealed on 3/8/25 CNA1 punched in to work the evening shift at 2:47 pm and punched out at 0:00 (midnight) and continued to work the night shift, then punched out on 3/9/25 at 7:01am. On the same day 3/9/25 at 2:46 pm, CNA1 punched in to work evening shift, then punched out at 0:00 (midnight) and continue to work the night shift, then punched out on 3/10/25 at 7:03am. On the same day 3/10/25 at 2:40 pm CNA1 punched in to work pm shift, then punched out at midnight, and continue to work the night shift, then punched out on 3/11/25 at 7:02 am. On the same day 3/11/25 at 3:01pm CNA1 punched in to work evening shift, then punched out at 11:02 pm ( a total of seven shifts in 4 days).

During a review of the Nursing Staffing Assignment and Sign-in Sheet on 3/14/25 at 10:40 am with the DSD, indicated 3/8/25, 3/9/25, and 3/10/25 night shift one CNA called off. The DSD confirmed there was one CNA staffing shortage for the night shift. and CNA1 worked to cover the shortage.

During an interview on 3/12/25 at 12:10 pm with LVN 1, LVN1 stated she filed a grievance on 1/5/25 she saw CNA1 was sleeping during work hours on many occasions and did not provide necessary care to her assigned residents that were found with soiled briefs and were not repositioned in bed, improperly responding to a resident ' s fall, and taking extended breaks than set schedule, and she was away from assigned unit during work. LVN 1 stated she did not remember how many times she told the supervisors about issues with CNA1. LVN 1 stated CNA1 hasn ' t improved in any way, which is really dangerous to the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 055181 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055181 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 3/14/25 at 12:30pm with CNA1, CNA1 stated she informed the charge nurse or relief CNA by saying I ' m going to break. CNA1 stated They (CN) didn ' t listen to me sometimes. They can ignore Level of Harm - Minimal harm or but I still had to go. I don ' t know about what residents ' safety can be affected but they should listen and potential for actual harm understand that I need to take my break. Regarding working double shifts CNA1 stated she was not certain if

the facility was short staffing but when there ' s someone called off, they asked everyone if someone would Residents Affected - Some stay over. CNA1 stated she spontaneously offered herself, she felt she could do the job, and the facility did not say no.

During an interview on 3/14/25 at 10:40am, the DSD stated they are in the process of hiring and they hire new staff every month. DSD stated the facility was not using staffs from the nursing agency (a service provider agency which provides nurses and healthcare assistants)anymore, and because the facility needed nursing staff on the floor to cover staffing shortage. DSD stated, the facility did not reject when CNA1 offered to help work extra shift. The DSD stated she monitors CNA1 ' s performance by inquiring feedback from charge nurses. The DSD thought CNA1 deserves an opportunity to improve. The DSD did not respond to the surveyor ' s questions when asked if the facility allows staff who already received warning about their poor performance to continued work residents.

During a review of the facility ' s Policy and Procedure (P&P) titled Staffing: Sufficient, Competent Nursing dated Year 2001, the P&P indicated the facility will provide sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care services for all residents in accordance with resident care plans and the facility assessment. The facility defines a Competent Staff:

1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.

2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 055181