The November 14 inspection followed a complaint about restraint use at the 91732 Buffington Road facility. Multiple certified nursing assistants described witnessing residents bound to chairs in ways that prevented them from getting up on their own.
"In the early morning I have seen residents that are already in chairs covered with blankets and tied to the Geri chairs," one nursing assistant told inspectors during an 11:41 p.m. interview. Geri chairs are large, padded, reclining chairs commonly used in nursing homes.
The assistant could not provide names of specific residents or say exactly when these incidents occurred.
Another nursing assistant explained that tying a sheet around a resident in a wheelchair constitutes a restraint "if the resident cannot untie the sheet and get out of the wheelchair on their own." This assistant also reported seeing residents tied to wheelchairs but could not identify which residents or provide specific dates.
A third nursing assistant told inspectors that "a restraint is a form of abuse because it restricts freedom of movement" and claimed the facility did not use restraints.
Federal inspectors reviewed medical records for at least one resident and found no physician orders authorizing any type of physical restraint during that person's stay at the facility.
The facility's own policy, revised in September 2017, explicitly states that residents have the right "to be free from mental and physical abuse" and "to be free from psychotherapeutic drugs and physical restraints used for the purpose of discipline or staff convenience."
The policy emphasizes that residents have "a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility."
Physical restraints in nursing homes require specific physician orders and must meet strict medical criteria. Using restraints for staff convenience or to control behavior violates federal regulations protecting nursing home residents' rights.
The inability of nursing assistants to provide specific details about the alleged restraint use — including which residents were involved and when incidents occurred — complicated the inspection. However, multiple staff members independently described similar scenarios involving residents tied to chairs.
The Gardens of El Monte must now develop a plan to correct the identified deficiency and submit it to state survey officials. The facility is required to address how it will ensure physical restraints are only used when medically necessary and properly ordered by physicians.
The inspection was triggered by a complaint, suggesting someone with knowledge of the facility's operations was concerned enough about restraint practices to contact authorities. Complaint-driven inspections often focus on specific allegations rather than comprehensive facility reviews.
Nursing home restraint violations have drawn increased federal scrutiny in recent years. The Centers for Medicare and Medicaid Services has emphasized that physical restraints should be used only as a last resort and never for staff convenience or behavior control.
The discrepancy between what nursing assistants reported seeing and what facility records showed highlights ongoing challenges in nursing home oversight. Staff members described witnessing practices that, if accurate, would violate both federal regulations and the facility's own policies.
The inspection found the violation caused "minimal harm or potential for actual harm" and affected "few" residents, according to federal classification standards. However, any unauthorized use of physical restraints represents a serious breach of resident rights and dignity.
The Gardens of El Monte now faces the requirement to demonstrate how it will prevent future restraint violations and ensure all staff understand proper restraint policies and procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Gardens of El Monte from 2025-11-14 including all violations, facility responses, and corrective action plans.