Mount San Antonio Gardens
Pomona · 0.1 mi · 520 beds
CitationsNoneSubstantiated0
Mount San Antonio Gardens
900 E. HARRISON AVE, Pomona, CA, 91767
6 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 5 deficiencies against Mount San Antonio Gardens in Pomona, California at its most recent standard inspection on 2025-05-30, 1 of them arising from complaints. Medicare rates it 5 out of 5 overall.
5 / 5Medicare overall rating
64certified beds
5deficiencies at the last inspection — opens the federal record at Medicare.gov0immediate-jeopardy findings on record — opens the federal record at Medicare.gov0actual-harm findings on record
0federal fines
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.0
Actual harmA resident was harmed, but not placed in immediate danger.0
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.17
Potential for minimal harmThe least serious band.0
Most recentDDDDDEDDDEEDDDDDD
The last 17 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2026-01-22 · from a complaint · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2025-05-30 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · F0690 · 2025-05-30 · standard survey · No actual harm, potential for more than minimal harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · F0700 · 2025-05-30 · standard survey · No actual harm, potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · F0842 · 2025-05-30 · standard survey · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2024-05-16 · standard survey · No actual harm, potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · F0641 · 2024-05-16 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · F0684 · 2024-05-16 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2024-05-16 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · F0688 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · F0550 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · F0558 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · F0695 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · F0759 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · F0805 · 2023-05-26 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below5 of 5
Health inspectionBased on the last three inspection cycles5 of 5
StaffingNurse hours per resident, adjusted for how sick residents are3 of 5
Quality measuresResident outcomes reported by the home5 of 5
Nurse hours per resident per dayReported by the home to CMS5.95393
Ownership
Who owns Mount San Antonio Gardens
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| CONGREGATIONAL HOMES | Organization | 100% | since 06/09/2007 |
| ABRAMS, LISE | Individual | NOT APPLICABLE | since 01/01/2023 |
| ASPINALL, ROBIN | Individual | NOT APPLICABLE | since 01/01/2023 |
| BROWN, ELEANOR | Individual | NOT APPLICABLE | since 01/01/2021 |
| BROWN, EVELYN | Individual | NOT APPLICABLE | since 01/06/2022 |
| BUSH, JAN | Individual | NOT APPLICABLE | since 01/01/2023 |
| GERARD, NEIL | Individual | NOT APPLICABLE | since 01/01/2023 |
| GRIGSBY, JILL | Individual | NOT APPLICABLE | since 01/01/2023 |
| HARPOLE, JOHN | Individual | NOT APPLICABLE | since 01/01/2021 |
| LEE, CAMILLE | Individual | NOT APPLICABLE | since 01/01/2025 |
| MENEFEE LIBEY, DAVID | Individual | NOT APPLICABLE | since 01/01/2021 |
| MURPHY, RACHELLE | Individual | NOT APPLICABLE | since 01/01/2023 |
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
2ND Choice
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CitationsNoneSubstantiated0
Sunray Assisted Living
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Pilgrim Place Health Services Center
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Contact
Ask Mount San Antonio Gardens a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 055016.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction