Health inspection·December 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) was treated with respect and dignity by failing to ensure Activities Assistant (AA) 1 allowed Resident 5 to get up from the reclining wheelchair (wheelchair with backrest that moves backward so users can transition from an upright seated position to a horizontal position) on 12/1/2025 at 1:25 pm. This failure resulted in Resident 5 being confined (restricted) to Resident 5's reclining wheelchair and had the potential for Resident 5 to develop a decline in range of motion (ROM- how far and in what direction a joint or muscle can move), the ability to stand, quality of life, and lead to psychosocial (mental, emotional, social, and spiritual effects) harm.Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 7/11/2025 with diagnoses that included abnormalities of gait and other mobility (inability to walk normally due to injuries or underlying conditions), other lack of coordination (uncoordinated movement due to muscle control that causes an inability to coordinate movements) and cognitive communication deficit (a common consequence of brain injuries that affects the ability to communicate effectively). During a review of Resident 5's untitled Care Plan (CP) dated 10/3/2025, the CP indicated Resident 5 had the potential for impaired physical mobility related to limited movement. The CP goals indicated Resident 5 would demonstrate full ROM of the affected limb daily, for 3 months. The CP approach plan indicated to encourage Resident 5 to participate in his/her own care and decision-making to the extent permitted by his/her condition, and to encourage Resident 5 to the activity of choice. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 10/15/2025, the MDS indicated Resident 5 had severely impaired cognition (ability to think, reason, and function). The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with sitting to lying, lying to sitting on side of bed, rolling left and right (in bed), sitting to standing, chair/bed-to-chair transfers, toilet transfers and walking 50 feet. During an observation on 12/1/2025 at 7:49 am, in the dining room, Resident 5 was observed. Resident 5 was observed in a large reclining wheelchair with high back and foldable sides near the shoulders and head. The chair itself resembled a sitting chair (on wheels). The chair was tilted back. Resident 5 was observed lying in the chair, with Resident 5's feet up in the footrest. During an observation on 12/1/2025 at 9:12 am, in the dining room, Resident 5 was observed. Resident 5 was in the large, reclining chair, at one of the tables, with the chair titled back, and Resident 5's feet up in the footrest. During an observation on 12/1/2025 at 11:30 am, in the dining room, Resident 5 was observed. Resident 5 was in the large, reclining chair, at one of the tables, with the chair titled back, and Resident 5's feet up in the footrest. During a concurrent observation and interview on 12/1/2025 at 12:16 pm, with Licensed Vocational Nurse/Treatment Nurse (LVN) 1, Resident 5 was observed in the dining room. Resident 5 was in the reclining wheelchair with the head titled back. LVN 1 stated, Resident Page 1 of 3 555903 555903 12/01/2025 The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732

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 555903 Page 2 of 3 555903 12/01/2025 The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 555903 Page 3 of 3