Inspection visit

Health inspectionDecember 23, 2024

THE GARDENS OF EL MONTECMS #5559033 citations on this visit

3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify one of three sampled residents' (Resident 7) Responsible Party (RP- a person who makes decisions for a resident) that the resident had fallen (to suddenly go down onto the ground or toward the ground) while in the care of the facility. This failure had the potential to deny Resident 7's right for her representative to be informed of Resident 7's health status. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/1/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), and dementia (a group of thinking and social symptoms that interferes with daily functioning). The AR indicated Resident 7's daughter (RP 1) was Resident 7's Responsible Party. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2024, the MDS indicated Resident 7 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). During a concurrent observation and interview on 12/19/2024, at 10:43 a.m. with RP 1, RP 1 was sitting in the facility hallway next to Resident 7. Resident 7 was sitting in her wheelchair. RP 1 stated Resident 7 had been a resident at the facility for a month. RP 1 stated Resident 7 had a history of falls but had never fallen at the facility. During a concurrent interview and record review on 12/19/2024, at 12:22 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 7's Situation-Background-Appearance- Review and Notify Communication Form (SBAR) dated 12/19/2024 was reviewed. The SBAR indicated Resident 7 was found on the floor next to Resident 7's bed on 12/19/2024 at around 4:30 a.m. LVN 1 confirmed Resident 7 fell at around 4:00 a.m. The SBAR indicated LVN 1 notified RP 1 on 12/19/2024 at 7 a.m. of Resident 7's fall. During a telephone interview on 12/23/2024 at 12:13 p.m. with RP 1, RP 1 stated the facility had not informed RP 1 that Resident 7 fell on [DATE]. RP 1 stated during a visit with Resident 7, RP 1 noticed a bruise on Resident 7 and asked facility staff (unidentified) what had happened to Resident 7. RP 1 stated none of the staff knew where Resident 7's bruise was from. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555903 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732 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 0580 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 12/23/2024, at 1:27 p.m. with LVN 1, Resident 7's SBAR dated 12/19/2024 was reviewed. The SBAR indicated LVN 1 notified RP 1 on 12/19/2024 at 7 a.m. of Resident 7's fall. LVN 1 stated LVN 1 had called RP 1 but did not leave a detailed voicemail about Resident 7's fall. LVN 1 stated LVN 1 did not notify RP 1 that Resident 7 had fallen at the facility. LVN 1 stated RP 1 needed to be informed of Resident 7's fall because RP 1 was Resident 7's Responsible Party. Residents Affected - Few During an interview on 12/23/2024 at 2:38 a.m. with the Director of Nursing (DON), the DON stated charge nurses needed to call residents' (in general) family members/responsible parties when a resident (in general) experienced a fall while at the facility. During an interview on 12/23/2024 at 3:20 p.m. with the DON, the DON stated the facility did not have a policy and procedure (P&P) regarding notifying responsible parties of residents' (in general) falls or changes of conditions (COC). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a daily skin assessment for one of one sampled resident (Resident 8) who was at risk of developing skin breakdown and pressure injuries (localized areas of skin damage caused by prolonged or intense pressure). Residents Affected - Few This failure had the potential for Resident 8 to develop skin breakdown and pressure injuries and/or to not receive treatment for skin breakdown and pressure injuries. (Cross Reference F842) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 10/31/2024, and readmitted Resident 8 on 12/6/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), metabolic encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 11/4/2024, the MDS indicated Resident 8 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 8 required partial/moderate (helper does less than half the effort) assistance from staff for eating and oral, toileting, and personal hygiene. The MDS indicated Resident 8 was at risk of developing pressure injuries. The MDS indicated Resident 8 had no unhealed pressure injuries but had open lesion(s) other than ulcer, rashes, or cuts. During a review of Resident 8's Comprehensive Resident Assessment (AA, admission assessment), dated 12/6/2024, timed at 3:30 p.m., the AA indicated Resident 8's skin condition included a healing scar on Resident 8's left forehead. During a concurrent observation, interview, and record review on 12/20/2024 at 10:56 a.m. with the Assistant Director of Nursing (ADON), Resident 8 was observed sitting in the dining room. Resident 8's nose was noted to have a small healing laceration (a pattern of injury in which skin and underlying tissues are cut or torn). The ADON stated the wound looked like a skin tear. There was yellow discoloration noted on both sides of Resident 8's nose and under his eyes. The ADON stated Resident 8 already had those injuries when the facility readmitted Resident 8 on 12/6/2024. The ADON reviewed Resident 8's AA, dated 12/6/2024, timed at 3:30 p.m., and stated Resident 8's AA did not have documentation of Resident 8's nose laceration and discoloration on both side of his nose and under his eyes. The ADON stated Treatment Nurse (TN) 1 completed Resident 8's AA. During a concurrent interview and record review on 12/23/2024 at 10:14 a.m. with Registered Nurse (RN) 1, Resident 8's Daily Skilled Nurse's Notes (Daily Notes), dated 12/22/2024 and 12/23/2024 were reviewed. The Daily Notes did not indicate Resident 8 had a laceration on his nose. RN 1 stated RN 1 did not do a physical assessment of Resident 8 when completing the Daily Note. RN 1 stated RN 1 copied the skin assessment information from the AA, dated 12/6/2024 and transcribed the skin assessment to the Daily Note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732 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 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/23/2024 at 2:38 p.m. with the Director of Nursing (DON), the DON stated the Daily Note document was completed daily for residents (in general) on Medicare (federal health insurance program for anyone age [AGE] and older, and some people under 65 with disabilities). The DON stated the nurse who completed the Daily Note must physically assess the residents (in general) to ensure skin issues were documented accurately and to also ensure new skin issues were treated. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, admission Policy, revised 1/2017, the P&P indicated, On admission, based on information accompanying the resident and results of admission assessment completed by the licensed nurses, a baseline care plan will be developed to address minimum health care information required to properly care for reach resident, including goals and objectives. The P&P indicated, the care plan must address effective and person centered care that meets professional standards of quality of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 8) by failing to accurately document skin assessments in Resident 8's medical record. This failure resulted in Resident 8's medical record to contain inaccurate information and had the potential to affect Resident 8's care. (Cross Reference F684) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 10/31/2024, and readmitted Resident 8 on 12/6/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), metabolic encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2024, the MDS indicated Resident 8 was severely impaired (never/rarely made decisions) impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 8 required partial/moderate (helper does less than half the effort) assistance from staff for eating and oral, toileting, and personal hygiene. The MDS indicated Resident 8 was at risk of developing pressure injuries. The MDS indicated Resident 8 had no unhealed pressure injuries but had open lesion(s) other than ulcer, rashes, or cuts. During a review of Resident 8's Comprehensive Resident Assessment (AA, admission assessment), dated 12/6/2024, timed at 3:30 p.m., the AA indicated Resident 8's skin condition included a healing scar on Resident 8's left forehead. During a concurrent observation, interview, and record review on 12/20/2024 at 10:56 a.m. with the Assistant Director of Nursing (ADON), Resident 8 was observed sitting in the dining room. Resident 8's nose was noted to have a small healing laceration (a pattern of injury in which skin and underlying tissues are cut or torn). The ADON stated the wound looked like a skin tear. There was yellow discoloration noted on both sides of Resident 8's nose and under his eyes. The ADON stated Resident 8 already had those injuries when the facility readmitted Resident 8 on 12/6/2024. The ADON reviewed Resident 8's AA, dated 12/6/2024, timed at 3:30 p.m., and stated Resident 8's AA did not have documentation of Resident 8's nose laceration and discoloration on both side of his nose and under his eyes. The ADON stated Treatment Nurse (TN) 1 completed Resident 8's AA. During a concurrent interview and record review on 12/23/2024 at 10:14 a.m. with Registered Nurse (RN) 1, Resident 8's Daily Skilled Nurse's Notes (Daily Notes), dated 12/22/2024 and 12/23/2024 were reviewed. The Daily Notes did not indicate Resident 8 had a laceration on his nose. RN 1 stated RN 1 did not do a physical assessment of Resident 8 when completing the Daily Note. RN 1 stated RN 1 copied the skin assessment information from the AA, dated 12/6/2024 and transcribed the skin assessment to the Daily Note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732 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 0842 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 12/23/2024 at 10:25 a.m. with TN 1, Resident 8's AA, dated 12/6/2024 was reviewed. The AA failed to indicate the injuries to Resident 8's nose and the discoloration around his eyes. TN 1 stated Resident 8 had the injuries to Resident 8's nose and the discoloration around his eyes when Resident 8 was readmitted to the facility on [DATE]. TN 1 stated she forgot to document Resident 8's injuries to his nose. Residents Affected - Few During an interview on 12/23/2024 at 2:38 p.m. with the Director of Nursing (DON), the DON stated a Daily Note document was completed daily for residents (in general) on Medicare (federal health insurance program for anyone age [AGE] and older, and some people under 65 with disabilities). The DON stated the nurse who completed the Daily Note must physically assess the residents (in general) to ensure skin issues were documented accurately and to also ensure new skin issues were treated. During a review of the facility's policy and procedure (P&P) titled, Documentation Principles, revised 2/2018, the P&P indicated, It is the policy of the facility that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. The P&P indicated Entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 6 of 6

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Citations

3 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the December 23, 2024 survey of THE GARDENS OF EL MONTE?

This was a inspection survey of THE GARDENS OF EL MONTE on December 23, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE GARDENS OF EL MONTE on December 23, 2024?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 23, 2024