Skip to main content
Advertisement
Complaint Investigation

The Gardens Of El Monte

Inspection Date: November 14, 2025
Total Violations 2
Facility ID 555903
Location EL MONTE, CA
Advertisement

Inspection Findings

F-Tag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

restraint if the resident cannot untie the sheet and get out of the wheelchair on their own. CNA 1 was unable to state the names of the residents, how many residents, and when CNA 1 saw residents tied to wheelchairs. During an interview on 11/14/25 at 11:41 p.m. with CNA 2, CNA 2 stated, A restraint is when you tie up a patient and hold them from doing something. CNA 2 was asked, Do you ever see residents tied to chairs, so they can't get up? CNA 2 stated, In the early morning I have seen residents that are already in chairs covered with blankets and tied to the Geri chairs [a large, padded, and reclinable chair]. CNA 2 was unable to state the names of the residents, how many residents, and when CNA 2 saw residents tied to Geri chairs. During an interview on 11/14/25 at 1:04 p.m. with CNA 4, CNA 4 stated, A restraint is a form of abuse because it restricts freedom of movement. CNA 4 stated the facility did not use restraints. During a

review of Resident 2's medical record, there were no physician orders for any type of restraint during Residents 2's stay at the facility. During a review of the facility's current Policy & Procedure (P&P) titled, Resident Rights, revised 9/2017, the P&P indicated, Policy: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: 1) To be free from mental and physical abuse; 2) To be free from psychotherapeutic drugs and physical restraints used for the purpose of discipline or staff convenience. During a review of Resident 2's medical record, there were no physician orders for any type of restraint during Residents 2's stay at the facility.

During a review of the facility's current Policy & Procedure (P&P) titled, Resident Rights, revised 9/2017,

the P&P indicated, Policy: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: 1) To be free from mental and physical abuse; 2) To be free from psychotherapeutic drugs and physical restraints used for the purpose of discipline or staff convenience.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

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)

Advertisement

F-Tag F0742

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited THE GARDENS OF EL MONTE in EL MONTE, CA for a deficiency under regulatory tag F-F0742 during a complaint investigation conducted on 2025-11-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of THE GARDENS OF EL MONTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-11.

📋 Inspection Summary

THE GARDENS OF EL MONTE in EL MONTE, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL MONTE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE GARDENS OF EL MONTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
« Back to Facility Page
Advertisement
Advertisement