The Gardens of El Monte

In the surveyor’s words

From the most serious findings on record at The Gardens of El Monte, in the surveyor’s own words.

• Actual harm, isolatedF692Jun 17, 2024

  Based on interview and record review, the facility failed to provide adequate (satisfactory or acceptable in quality or quantity) hydration (process of replacing water in the body through drinking water and eating food with high water content so every cell, tissue, and organ can properly function) for one of two sampled residents (Resident 1) as indicated in Resident 1's Untitled Care Plan (UPC), dated 5/16/2024, and the facility's policy and procedure (P&P) titled, Hydration Management, and Intake (the measurement of the fluids that enter the body) and Output (the fluids that leave the body), by failing to: 1. […]

• No harm, potential for more than minimal, patternF684Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being, when the facility failed to: a. Timely renew Resident 4's wound treatment order for the right lower leg after the last treatment given on [DATE]. The order expired on [DATE]. b. Timely renew Resident 4's wound treatment order for the forehead after the last treatment given on [DATE]. The order expired on [DATE]. As a result, Resident 4 did not receive wound treatment of the right lower leg for 21 days and wound treatment of the forehead for 17 days. […]

• No harm, potential for more than minimal, patternF684Jun 24, 2026

  Based on interview and record review, the facility failed to:1. Send Resident 1 for timely medical treatment after falling and hitting his head on the floor.2. Ensure three of five sampled residents (Resident 3, Resident 4, and Resident 5) received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring (involves measuring blood pressure (BP) while lying down, sitting, and standing to assess changes) by failing to ensure Resident 3, Resident 4, and Resident 5 were monitored for orthostatic hypotension (condition in which the blood pressure quickly drops upon standing up after sitting or lying down) with two blood pressure (BP) readings on 6/7/26, 6/14/26 and 6/21/26 and observed for adverse side effects.These deficient practices had the… […]

• No harm, potential for more than minimal, patternF761Jun 24, 2026

  Based on observation, interview, and record review, the facility failed to maintain proper storage of medications in one of two medication carts (Medication Cart 1).This deficient practice had the potential for medication dispensing errors for 25 residents who resided in the facility's Station 1 Unit. During an observation of Medication Cart 1 on 6/23/26 at 2:15 p.m., in Station 1 Unit, with Licensed Vocational Nurse 1 (LVN 1), the locked narcotics (a drug that is classified as a Schedule IV controlled substance and in moderate doses dulls the senses, relieves pain, and induces sleep) drawer with active medications was observed with 4 loose medications in the back of the narcotics drawer. […]

• No harm, potential for more than minimal, patternF609Jun 4, 2026

  Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Prevention, for two of three sampled residents (Resident 6 and Resident 7) when the facility did not report two resident to resident abuse allegations (a claim that abuse has occurred) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours. This failure resulted in the delay of notification to the Department and had the potential for Resident 6 and Resident 7 to be subjected to abuse while at the facility. A. […]