Cycle 1
Health 2025-03-16 · Fire 2025-03-16
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
El Monte, CA
The Gardens Of El Monte
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5044 Buffington Rd, El Monte, CA
(626) 443-1351
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mandelbaum Family
Operator or chain grouping
Approved since
2017-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing
LPN hours / resident day
1.49
Licensed practical nurse staffing
Aide hours / resident day
2.65
Nurse aide staffing
Weekend hours
3.92
Weekend nurse staffing
RN turnover
83%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.3
1 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
1.6%
0.1 pts worse
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
6.8%
3.1 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.0% |
4.1%
2.9 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.4% |
13.7%
35.7 pts worse
|
19.6%
29.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 47.1% |
14.2%
32.9 pts worse
|
16.7%
30.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.7% |
11.0%
5.7 pts worse
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
10.7%
18.9 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.2%
2.5 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.5% |
10.9%
7.4 pts better
|
19.8%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.7%
0.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
11.2%
6.1 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.2%
3 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
23.2%
6.2 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-03-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-17
D · Potential for more than minimal harm
2024-03-15
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-15
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-04-14
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-05-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-12
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-01-11
E · Potential for more than minimal harm
2025-12-12
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-11
E · Potential for more than minimal harm
2025-12-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-12-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-12-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2026-01-11
D · Potential for more than minimal harm
2025-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-25
D · Potential for more than minimal harm
2025-11-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-11-14
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-11-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-06
E · Potential for more than minimal harm
2025-03-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-07
B · Minimal harm
2025-03-16
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-04-07
D · Potential for more than minimal harm
2024-12-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-08-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-30
G · Actual harm
2024-06-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-04-16
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-04-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
B · Minimal harm
2024-03-15
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-08-15
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-05-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-12
B · Minimal harm
2023-04-14
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$0
2024-06-17
Payment Denial
Payment Denial · denial start 2024-07-17 · 1 days
1 day denial
Ownership
Global Skilled LLC
5% Or Greater Direct Ownership Interest · Organization
The Bentzion Mandelbaum 2021 Irrevocable Gift Trust No. 2
5% Or Greater Indirect Ownership Interest · Organization
Simcha And Janet Mandelbaum Family Trust
5% Or Greater Indirect Ownership Interest · Organization
The Janet Mandelbaum 2021 Irrevocable Gift Trust No 2
5% Or Greater Indirect Ownership Interest · Organization
The Simcha Mandelbaum 2021 Irrevocable Gift Trust No. 2
5% Or Greater Indirect Ownership Interest · Organization
Mandelbaum, Janet
Corporate Officer · Individual
Yanguba, Chondala
W-2 Managing Employee · Individual
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