Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greater El Monte Community Hos during CMS and state inspections, most recent first.
A facility failed to keep resident rooms within the stated acceptable temperature range, leaving two residents in a shared room at 64 degrees F and another resident’s room at 60 degrees F. The affected residents had significant medical needs, including vent dependence, tracheostomy-related care, chronic respiratory failure, COPD, and severe cognitive impairment. Staff and leadership acknowledged that room temperatures should be maintained around 68-75 degrees F, but the facility did not typically monitor room temperatures daily and relied on staff to identify problems and notify engineering.
Improper Storage of Damaged Cans and Low Sanitizer Levels Two dented cans of enchilada sauce were found stored with usable food in the dry-storage area instead of being separated as damaged stock. In the main kitchen, 2 of 4 sanitation buckets tested below the required quaternary sanitizer range of 150 ppm to 400 ppm, and the HC and DS stated the solution was not at an effective strength for sanitizing food-contact surfaces.
Failure to develop a care plan for DM for a resident with an active DM diagnosis. RN reviewed the resident’s care plans and confirmed there was no DM care plan, while the DON stated such a plan was important to address the disease process and support communication with the doctor. The facility’s care planning policy stated each diagnosis would be listed and updated as necessary.
A resident with severe cognitive impairment, hemiplegia/hemiparesis, and an unhealed stage 2 PU developed a sacral stage 2 PU and then a new left heel DTI. Staff did not consult the dietician after the new PU developed, no IDT was held, and the resident’s left heel was observed resting on the sheet without the ordered heel protector despite the care plan and PNOR calling for heel offloading.
Failure to Flush Indwelling Urinary Catheter: A resident with an indwelling urinary catheter had bloody and cloudy sediment noted in the catheter tubing, and staff acknowledged the catheter had not been flushed as ordered. The resident had diagnoses including BPH, and the care plan directed staff to monitor and maintain catheter patency; RN and LVN interviews confirmed the need to flush the catheter to prevent occlusion.
Feeding Tube Water Flush Bag Not Dated: The facility failed to ensure a resident with a gastrostomy tube had the enteral water flush bag labeled and dated per policy. Staff observed the bag without a first-use date, and RN and DON confirmed the bag should be dated to track use and support resident safety. The resident had chronic respiratory failure, was ventilator-dependent, and received ordered tube flushes before and after medication administration.
Soiled tracheostomy tube not cleaned as ordered: A resident with chronic respiratory failure, ventilator dependence, and a trach had old bloody residue observed in the inner part of the trach tube. The PNOR directed daily and PRN cleaning of the inner cannula and trach tie if soiled, and the care plan called for trach care as ordered. RT stated the bloody drainage had not yet been cleaned, and the DON confirmed it should have been cleaned to help prevent infection.
A resident with a G-tube, chronic respiratory failure, COPD, and severely impaired cognition had a tube-feeding syringe containing gastric contents left on the bedside table inside wrapper packaging. An LVN stated the syringe should have been discarded immediately after checking gastric residuals, and the DON confirmed it should have been removed from the bedside after use.
Resident room had active water intrusion and wall deterioration. A resident with chronic respiratory failure, COPD, and CVA had severe cognitive impairment and was dependent for ADLs and mobility. Surveyors observed heavy rain entering the room through the window area, with moisture, staining, peeling, and separation of wall material above the window and water drops on the blinds. The SE and Lead Engineer stated the leak had been known for about a week and was related to rain, drainage backup, and a seal that did not appear to have been properly installed.
Resident rooms were maintained below acceptable temperature levels
Penalty
Summary
The facility failed to ensure three sampled residents were provided a safe and comfortable homelike environment when their rooms were kept at temperatures below the facility’s stated acceptable range. Resident 9 was admitted with multiple diagnoses including respiratory failure and sepsis, was vent dependent and nonverbal, and was dependent on staff for ADLs. Resident 11 was admitted with sepsis, a liver mass with possible bowel obstruction, and tracheostomy-related care needs, had chronic respiratory failure and vent support, and was dependent for ADLs. Both residents shared a room that, during observation, had a wall-mounted thermometer reading 64 degrees Fahrenheit. During the same observation and interview, a CNA stated the room temperature was 64-66 degrees and could be too cold for the residents, and that proper room temperature was important so the residents would not have hypothermia and would be comfortable. The facility’s Stationary Engineer stated resident room temperatures needed to be between 68 and 72 degrees Fahrenheit for safety and comfort, while the DON stated room temperature should be above 68 degrees Fahrenheit and staff should check temperatures more when the weather changes. The Lead Engineer stated maintenance was not responsible for checking room temperatures and that communication about temperature problems was only verbal. Resident 10 was admitted with chronic respiratory failure, COPD, and cerebrovascular disorder, and was severely cognitively impaired and dependent on staff for ADLs and mobility. During observation in Resident 10’s room, the wall-mounted thermometer showed 60 degrees Fahrenheit. An LVN stated this temperature was too low for Resident 10’s comfort and that resident rooms should generally be set at 70 degrees Fahrenheit. The facility’s policy titled Temperature and Humidity Monitoring stated temperature range from 68-75 degrees Fahrenheit, and the DF and SE both stated resident room temperatures should be maintained within that range, while also stating the facility did not typically monitor room temperatures daily.
Improper Storage of Damaged Cans and Inadequate Kitchen Sanitizer Levels
Penalty
Summary
Food was not stored and sanitized in accordance with professional standards in the main kitchen and dry-storage area. During an observation, two dented cans of enchilada sauce were found stored on the shelving designated for usable food items in the dry-storage area. The cans had dents along the sides, were not labeled, and were not placed in the designated area for compromised or damaged cans. During interview, the Purchasing Staff stated dented cans were supposed to be separated from intact canned goods upon delivery and kept out of meal service, and the Dietary Supervisor stated dented cans should not have been stored with usable stock because dents could compromise the can's integrity. The facility also failed to maintain adequate quaternary sanitizing solution in 2 of 4 sanitation buckets in the main kitchen. The Head Cook tested the buckets with quaternary test strips and found two buckets reading below 150 ppm, which was below the manufacturer's acceptable range of 150 ppm to 400 ppm. The Head Cook and Dietary Supervisor stated the solution needed to remain within that range to be effective for sanitizing food-contact surfaces and preventing cross-contamination. The facility policy and the manufacturer's instructions both required damaged cans to be discarded or separated from usable stock and sanitizer to be maintained at 150 ppm to 400 ppm.
Failure to Develop a Care Plan for Diabetes Mellitus
Penalty
Summary
The facility failed to provide a comprehensive care plan for one of four residents, Resident 2, because there was no care plan for diabetes mellitus (DM). Resident 2 was admitted on 4/25/2025 with a diagnosis that included acute chronic respiratory failure. The Minimum Data Set dated 8/6/2025 indicated Resident 2 had an active diagnosis of DM, and the History and Physical dated 10/9/2025 indicated Resident 2 was unable to complete the review of systems. During a concurrent interview and record review on 11/20/2025, RN 1 reviewed Resident 2’s care plans and stated Resident 2 did not have a care plan for DM. RN 1 stated it was important for Resident 2 to have comprehensive care plans to help direct care. During an interview on 11/21/2025, the DON stated it was important for Resident 2 to have a care plan that addressed DM to ensure the facility addressed the disease process and to aid communication with the doctor regarding Resident 2’s medical progress. The facility policy titled Care Planning stated the purpose was to assure a coordinated and comprehensive written plan based on the resident assessment instrument and individual needs of the resident, and that each diagnosis would be listed and updated as necessary.
Failure to Coordinate Pressure Injury Care and Follow Heel Offloading Plan
Penalty
Summary
The facility failed to provide preventive care for a resident who was at risk for pressure injuries and had multiple skin breakdowns. The resident was admitted with cerebrovascular disease and a tracheostomy, had severely impaired cognition, was dependent for activities of daily living and rolling, and was identified on the MDS as having hemiplegia or hemiparesis and one unhealed stage 2 pressure ulcer. The resident’s nutritional assessment listed improved skin integrity as a goal, and the care plan for the sacral stage 2 pressure ulcer included assessing nutritional needs to promote wound healing by the dietician. The resident developed an open area on the sacrum noted during morning care, and the wound was later documented as a stage 2 pressure ulcer measuring 2 cm by 2.5 cm by 1 cm with a red wound bed and slight exudate/odor. The resident also developed a new deep tissue injury on the left heel measuring 1.5 cm by 1.5 cm. Staff interviews confirmed that no dietician consultation was made when the new pressure ulcer developed, and no interdisciplinary team meeting was conducted in October 2025 after the pressure ulcer was identified. The CNM stated the facility did not notify her about the resident’s pressure ulcers. The resident’s care plan for the left heel deep tissue injury directed staff to use pillows to relieve pressure and apply a left heel protector at all times, and the physician’s nursing orders indicated both heels were to be elevated on pillows at all times. During observation, the resident was lying in bed with two pillows under the legs, the left heel resting on the fitted sheet, the right foot resting on top of the left foot, and no heel protector on the left foot. Staff acknowledged the heel should have been offloaded, and the DON stated an IDT should have been conducted for the resident’s pressure ulcer care.
Failure to Flush Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure proper care and services for one sampled resident with an indwelling urinary catheter when the catheter was not flushed as indicated by the Order Information Report dated 9/25/2025. Resident 5 was admitted on 8/11/2025 with diagnoses including chronic respiratory failure and hypertension, and a History and Physical dated 9/24/2025 documented benign prostatic hyperplasia. The resident’s Order Information Report showed sodium chloride irrigation was ordered for increased sediments, cloudiness, and hematuria, and the care plan initiated 9/25/2025 directed staff to monitor and maintain patency and placement of the suprapubic or indwelling catheter. During a concurrent observation and interview on 11/19/2025, bloody sediment was observed in the catheter tubing, and RN 1 stated the catheter should be flushed with normal saline to prevent occlusion and infection. On 11/20/2025, cloudy sediment was again observed in the catheter tubing, and LVN 2 stated awareness of the sediment but acknowledged the catheter tubing had not been flushed that day. LVN 2 also stated it was important to flush the catheter tubing to prevent occlusion. The resident’s MDS dated 10/6/2025 indicated severely impaired cognitive skills for daily decision making.
Feeding Tube Water Flush Bag Not Dated
Penalty
Summary
The facility failed to ensure that the enteral feeding water flush bag for Resident 11 was labeled and dated in accordance with its Policy and Procedure titled, Administration of Formula Via Feeding Tube, Gravity, Bolus Pump. Resident 11 was admitted with diagnoses including chronic respiratory failure, ventilator dependence, and a gastrostomy tube, and was unable to complete the review of systems. The physician's nursing orders included flushing the gastrostomy tube with 50 ml of water before medication administration and 20 ml after medication administration. During an observation in Resident 11's room, the water flush bag was seen without a date showing when it was first used. RN 2 stated the bag should be dated to show the first use date, and explained that this was important to prevent the resident from receiving old or expired fluids that could lead to infections. The DON also stated it was the facility's policy to date the water flush bag to ensure resident safety. The facility's policy stated that pump bags, syringe, and tubing are to be changed every 24 hours and properly labeled with date, time, and nurse's initials.
Soiled tracheostomy tube not cleaned as ordered
Penalty
Summary
Necessary respiratory care was not provided for a resident with a tracheostomy. Resident 11 was admitted with chronic respiratory failure, was on a ventilator, and had a gastrostomy tube. The physician's nursing orders dated 11/18/2025 directed staff to change and clean the resident's inner cannula and trach tie daily and as needed if soiled, and the care plan directed tracheostomy care as ordered to help prevent infection. During observation on 11/19/2025 at 9:56 AM, the inner part of Resident 11's tracheostomy tube was observed to be soiled with old bloody residue. During interview, the RT stated the tracheostomy was soiled and the bloody drainage should be cleaned as ordered, but had not yet been cleaned. The RT also stated the bloody residue could cause an infection if left in the tube. The DON later stated the bloody residue should have been cleaned to help prevent infection. The facility's P&P stated tracheostomy site care would be performed every shift and as needed.
Used Tube-Feeding Syringe Left at Bedside
Penalty
Summary
The facility failed to ensure that a tube-feeding syringe containing gastric contents was discarded after use and not left at the bedside for one of two sampled residents. Resident 10 was admitted on 10/15/2025 with diagnoses including chronic respiratory failure, COPD, and a G-tube. The MDS dated 10/27/2025 indicated Resident 10 had severely impaired cognition, was dependent for ADLs and mobility, and received tube feeding. During an observation on 11/19/2025 at 10:28 AM, a tube-feeding syringe containing gastric contents was seen on Resident 10's bedside table, left inside wrapper packaging. During interview, LVN 1 stated the syringe should have been discarded immediately after checking gastric residuals and that leaving a used syringe with gastric contents at the bedside was not consistent with infection-control practices. The DON later stated the syringe should have been discarded immediately after use and confirmed that used syringes with gastric content must be removed from the bedside to prevent contamination.
Resident Room Had Active Water Intrusion and Wall Deterioration
Penalty
Summary
The facility failed to maintain Resident 10’s room environment in a safe, comfortable, and sanitary condition by allowing an active roof leak and visible wall damage in the resident’s room. Resident 10 was admitted on 10/15/2025 with diagnoses including chronic respiratory failure, COPD, and cerebrovascular disorder. The resident’s MDS dated 10/27/2025 indicated severely impaired cognition and dependence for ADLs and mobility. During observation on 11/20/2025 at 3:30 PM, heavy rain was seen coming into Resident 10’s room through the window area, with moisture on the upper wall above the window, staining, discoloration, visible deterioration, peeling, separation of wall material, and water drops at the top of the window blinds. The Stationary Engineer stated the water leak had been known for about one week and that staff had reported the leak and damaged wall about one week earlier. The Lead Engineer stated the leak occurred during recent rain, that a drainage system along the exterior wall adjacent to the window tended to back up during heavy rain season, and that the area had been previously sealed off but the seal did not appear to have been properly installed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,006 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Manor Conv Hosp | 0.9 mi | ★★★★★ | 21 | 0 |
| Valley View Post Acute | 1.1 mi | ★★★★★ | 3 | 0 |
| Madera Post Acute Center | 2.2 mi | ★★★★★ | 26 | 0 |
| Eastland Subacute And Rehabilitation Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Penn Mar Healthcare Center | 2.5 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Greater El Monte Community Hos.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.