MONROVIA, CA - Staff at Monrovia Gardens Healthcare Center documented providing physical therapy exercises to a neurologically impaired resident on multiple days when they were not working at the facility, and admitted to falsifying medical records when treatment was incomplete or not provided at all, according to a February 2025 state inspection.
Missing and Incomplete Physical Therapy Services
The inspection revealed systematic failures in providing prescribed range-of-motion exercises to a resident with severe neurological conditions including conversion disorder, dysarthria, anarthria, and unspecified neuropathy. The resident, dependent on staff for most daily activities and cognitively impaired, was prescribed bilateral lower extremity active-assisted range-of-motion exercises five days per week.
State investigators discovered that nursing assistants RNA 1 and RNA 2 had documented providing these exercises on seven different dates in January and February 2025, despite not being present at work on any of those days. Both employees were no longer working at the facility when the violations were identified.
The falsification extended beyond absent staff members. RNA 5, who was present during the inspection, admitted to providing only one set of 10 repetitions instead of the prescribed three sets of 20 repetitions. When observed by investigators, RNA 5 was seen performing only a partial version of the ordered therapy.
Staff Admits to Falsifying Records
In interviews with state investigators, RNA 5 acknowledged the falsification was deliberate and widespread. The aide stated there were multiple dates in February when they either provided incomplete treatment or no treatment at all due to time constraints, yet still documented the services as completed.
"RNA 5 stated RNA 5 initialed Resident 2's RNFS on 2/25/2025 indicating the treatment was completed even though RNA 5 did not complete the treatment," according to the inspection report. The staff member acknowledged that this falsification prevented other caregivers from knowing the resident had not received proper care.
The resident confirmed these failures during an interview, stating that nursing assistants "either don't do it or only complete the order partially" when claiming to provide the prescribed exercises.
Medical Implications of Treatment Failures
Range-of-motion exercises are critical for residents with neurological conditions to maintain joint flexibility, prevent contractures, and preserve existing function. For patients with conditions affecting speech and motor control, these exercises can be the difference between maintaining independence and experiencing further physical decline.
The facility's Director of Staffing Development acknowledged the serious consequences, stating that if the resident did not receive prescribed services, they "could have a decline in mobility that could cause Resident 2 to be unable to use Resident 2's limbs and would make Resident 2 more dependent with care and activities of daily living."
RNA 5 similarly recognized the health impacts, telling investigators that missing treatments could cause the resident to "become contracted, be in pain, and have a loss of function." Contractures, or permanent muscle shortening, can develop rapidly in immobilized patients and are often irreversible once established.
Violation of Documentation Standards
The falsification violated both federal regulations and the facility's own policies requiring accurate, complete documentation. A registered nurse at the facility confirmed that documenting incomplete or unperformed treatments constitutes "willful falsification of medical records."
The facility's documentation policy clearly states that medical records must be "objective, complete, and accurate" and should "facilitate communication between the interdisciplinary team regarding the resident's condition and response to care." When staff falsify records, it breaks this communication chain and can lead to inappropriate care decisions based on inaccurate information.
Federal regulations require that nursing homes ensure services are provided as ordered and properly documented. The systematic nature of the falsification - involving multiple staff members over several weeks - suggests broader supervisory and oversight failures.
Additional Issues Identified
Beyond the exercise therapy violations, the inspection identified concerns about the facility's ability to track staff attendance and verify service delivery. The Director of Staffing Development could not confirm whether the resident received any treatments on the seven dates when absent staff had documented providing care.
The case highlights the vulnerability of residents with cognitive impairments who may not be able to effectively advocate for themselves or report missing care. The resident's neurological conditions, including conversion disorder and speech difficulties, made them particularly dependent on accurate staff documentation and proper service delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Gardens Healthcare Center from 2025-02-26 including all violations, facility responses, and corrective action plans.
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