Health inspection·December 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5 was usually in the reclining wheelchair most of the day, in the dining room, and the head was generally titled back because Resident 5 was a fall risk. During a concurrent observation and interview on 12/1/2025 at 1:25 pm, with AA 1 in the hallway outside the dining room, Resident 5 was observed in the reclining wheelchair. Resident 5's wheelchair was slightly titled back with the footrest up. Resident 5 was attempting to get out of the chair when AA 1 put AA 1's hands on Resident 5's right shoulder and stated, No, no, you need to stay in the chair. AA 1 stated, [Resident 5] wants to get up but we can't allow [Resident 5] to (get up). Resident 5 frowned and stayed in the chair. During an interview on 12/1/2025 at 1:29 pm with AA 1, AA 1 stated Resident 5 was not allowed to get out of the wheelchair because Resident 5 was a fall risk and staff did not want Resident 5 up because they needed to assist Resident 5. AA 1 stated, We use the chair to keep [Resident 5] in there so [Resident 5] doesn't get up. Sometimes we tilt chair back so [Resident 5] is more comfortable and will stop [Resident 5] from trying to get up. During an interview on 12/1/2025 at 2:49 pm, with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 5 was not dependent (helper does ALL the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity). CNA 3 stated Resident 5 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort). CNA 3 stated Resident 5 could stand from the bed and transfer to the chair. CNA 3 stated Resident 5 was a fall risk because Resident 5 was unsteady. CNA 3 stated, Since I've been working here, [Resident 5] has been going in the reclining wheelchair. CNA 3 stated if a resident was in a reclining wheelchair and wanted to get out of the wheelchair, staff were supposed to get them out because, That was their right. CNA 3 stated if Resident 5 could not get out of the reclining wheelchair when Resident 5 wanted, it would be considered a restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident's body, cannot be easily removed by a resident, and restricts the resident's freedom of movement or access to their body). CNA 3 stated a restraint was anything that restricted free will or free movement of a resident. CNA 3 stated if Resident 5 could not get out of the reclining wheelchair it could take a toll on Resident 5 and lead to skin tears (a wound that happens when the layers of skin separate or peel back) or cuts, agitation and other behavioral problems. During an interview on 12/1/2025 at 3:08 pm, with the Registered/Licensed Occupational Therapist (OTR/L), the OTR/L stated a resident who was being kept in the wheelchair like Resident 5 was in so Resident 5 could not get up and potentially fall, that was considered a restraint. The OTR/L stated the reclining wheelchair was supposed to improve a resident's quality of life and care. The OTR/L stated Resident 5 not being allowed to get out of the chair when Resident 5 wanted was a hindrance (delay or obstruction) to Resident 5's quality of life. During an interview on 12/1/2025 at 3:31 pm with the OTR/L, the OTR/L stated if residents wanted to get up from the reclining wheelchair, staff were supposed to allow residents to stand up. The OTR/L stated the activities staff or other staff knew to ask rehabilitation staff for help if residents wanted to stand up to help relieve pressure or tension or had the urge and/or wanted to stand. During a concurrent interview and record review on 12/1/2025 at 3:557 pm with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Physical Restraints, was reviewed. The DON stated a reclining wheelchair was not a restraint. The DON stated, My staff are not educated to answer what a restraint is. The DON stated it was a violation of resident rights if staff were not getting residents up when they wanted and restricting residents' movement. The DON stated keeping residents in wheelchairs when they wanted to get up was not a restraint and if staff were answering that way, they needed to be educated because they were wrong. During a review of the facility's P&P (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 12/01/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete titled, Resident Rights, revised 9/2017, the P&P indicated the policy goal was to promote the exercise of rights for each resident, including any who face barriers (such as communication problems, vision or hearing problems, and cognition limits) in the exercise of those rights. The P&P indicated a resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. The P&P indicated a resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The P&P indicated a facility must protect and promote the rights of each resident, including each of the following rights.choose a physician, treatment, and participate in decisions and care planning in an ongoing basis.to participate in his/her treatment and support the resident by facilitating the inclusion of the resident or their representative, including an assessment of the resident's strengths and needs and incorporating the resident's personal and cultural preferences in the development of goals.to be free from.physical restraints used for the purpose of discipline or staff convenience. During a review of the facility's P&P titled, Physical Restraints, revised 9/2017, the P&P indicated it was the policy of the facility that restraints will only be used after other alternatives had been tried unsuccessfully and only with a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a care plan to address the use of restraint. The P&P indicated restraints were defined as any manual method or physical mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot easily remove easily which restricts freedom of movement or normal access to one's body. The P&P indicated physical restraints shall not be used to limit resident mobility for convenience of staff. Event ID: Facility ID: 555903 If continuation sheet Page 3 of 3