Health inspection·November 6, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few toileting hygiene, and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does more than half the effort) to walk and transfer. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/6/25, the SBAR indicated Resident 1 had a fall in hallway while ambulating (walking) with FWW [front-wheeled walker used to help a patient walk]. Resident 1 lost her balance and hit the left side of her forehead on the floor when landing. The SBAR indicated Resident 1 had a bump to the front of left forehead. The SBAR did not indicate, and there was no documented evidence in Resident 1's medical record, that a staff member supervised or assisted Resident 1 to walk with a FWW when Resident 1 fell on 9/6/25. During a review of Resident 1's medical record, there was no care plan regarding Resident 1's fall on 9/6/25 found in the medical record. Resident 1's care plan titled, At Risk for Fall/Injury related to History of Falls Prior to Admission, dated 8/21/25, was not updated after Resident 1 fell on 9/6/25. During a review of Resident 1's FRE, dated 9/6/25, the FRE indicated Resident 1's risk for fall was rated high risk with a score of 16. The form indicated a total score of 10 or above represented high risk for fall. During a review of Resident 1's Nurse Notes from 9/6/25 through 9/9/25 the notes indicated Resident 1 was on monitoring and Neuro-check (neurological exam, a group of questions and tests to check for disorders of the nervous system often performed after a suspected head injury) after a fall with bruising to left forehead. During a review of Resident 1's Status Post Fall Assessment (SPFA) completed by the physical therapist (PT), dated 9/8/25, indicated Resident 1 fell on 9/6/25 at 2:50 pm. The SPFA indicated Resident 1 was confused and did not remember falling. The SPFA indicated Resident 1 had bruises, swelling, and an open wound on the forehead. The assessment indicated Resident 1 needed supervision at all times according to the PT recommendations. During a review of Resident 1's SBAR and Nurse Notes dated 11/2/25, the SBAR and Nurse Notes indicated Resident 1 had a fall in Resident 1's room, next to the wheelchair and the bed. Resident 1 was found sitting on Resident 1's buttocks on the floor and was assessed with a right knee abrasion and small bump to the right side of the head. During a review of Resident 1's SPFA completed by the PT, dated 11/3/25, indicated, Resident remembered falling, but doesn't want to give detailed report. The SPFA indicated Resident 1 fell on [DATE] at 11:30 pm in Resident 1's bedroom. The SPFA indicated Resident 1 had bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face. The SPFA indicated Resident 1 needed supervision at all times according to the PT recommendations. During an interview on 11/5/25 at 1:55 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was familiar with Resident 1's care. LVN 1 stated she was aware of Resident 1's fall on 11/2/25. LVN 1 stated Resident 1 sustained a discoloration around the right eye from Resident 1's fall on 11/2/25. LVN 1 reviewed Resident 1's care plan titled, At Risk for Fall/Injury related to History of Falls Prior to Admission, dated 8/21/25, and stated the care plan was not changed or updated after 8/21/25. LVN 1 stated the facility's post fall protocol included assessing the resident for injury, completing a change of condition or SBAR, completing a fall incident report, completing a Status Post Fall Assessment (SPFA) by the rehabilitation department, a review of the fall incident report and the SPFA by the Interdisciplinary Team (IDT), the IDT making recommendations for resident's continued care, and updating or creating a fall care plan. During an interview on 11/5/25 at 2:11 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, When a resident falls, you check with the resident and ask what happened. You check the resident for injuries, and take vitals, then complete an incident report and update the care plan right away or initiate one if there is none. During an interview on 11/6/25 at 1:31 pm with the Director of Nursing (DON), the DON acknowledged Resident 1's care plan for At (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555903 If continuation sheet Page 2 of 3 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 11/06/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Risk for Fall/Injury related to History of Falls prior to Admission dated 8/21/25 was not updated after the 11/1/25 fall. The DON stated the care plan should be created or updated within 72 hours of a resident's fall to develop interventions or revise interventions to reduce the risk of future falls. During a review of the facility's current Policy & Procedure (P&P) titled, Falls by A Resident, revised 7/2017, the P&P indicated, It is the policy of the facility that if a resident sustains a fall, an incident report will be completed. A post fall assessment is also completed to identify factors that may have contributed to the fall. A care plan or an update to an existing care plan will then be generated.A post fall assessment is completed to identify possible causative factors that could have contributed to a fall. The information is then used to formulate a plan of care in an attempt to prevent further falls or accidents.The licensed nurse will complete the form as follows: Document on the post fall assessment that the care plan was updated to reflect an action plan or approaches developed for prevention of falls; If there is an existing care plan for falls, it should be updated to reflect newly identified risk factors or approaches developed; If there was no existing care plan, a care plan for prevention of falls will be developed. Event ID: Facility ID: 555903 If continuation sheet Page 3 of 3