Monrovia Gardens: Staff Falsified Therapy Records - CA
The resident, admitted in October 2023 with conversion disorder, complete inability to speak, and nerve damage, required daily assisted range-of-motion exercises for both legs. The physician ordered 20 repetitions, three sets each, five days per week.
But nursing assistant RNA 5 admitted to inspectors on February 26 that she provided only one set of 10 repetitions instead of the ordered three sets of 20. She also confessed to initialing the resident's treatment sheet on February 25 "indicating the treatment was completed even though RNA 5 did not complete the treatment."
When asked why she falsified the record, RNA 5 told inspectors she did it "because RNA 5 was supposed to."
The resident depends entirely on staff for toileting, dressing, and transferring from bed to chair. Federal assessments show the person requires substantial assistance with bathing, personal hygiene, and even rolling left or right in bed.
Two other nursing assistants falsified records on days they weren't even at work. RNA 1 and RNA 2 initialed the resident's therapy sheets on seven different days in January, but payroll records showed neither was clocked in on any of those dates.
The Director of Staffing Development confirmed to inspectors that RNA 2 signed off on providing therapy on January 16, 30, and 31, despite not working those days. RNA 1 initialed therapy records for January 24, 27, 28, and 29, but was also absent from work.
Both assistants no longer work at the facility. The director told inspectors she "could not say if Resident 2 received RNS" on any of those seven days.
During the inspection, the resident told investigators that nursing assistants "did not provide RNS to Resident 2 on 2/24/2025 or 2/25/2025." The resident said staff claim they're providing therapy "but they either don't do it or only complete the order partially."
RNA 5 admitted there were other unspecified dates in February when she "either did not give the complete treatment to Resident 2 or did not do Resident 2's RNS at all because RNA 5 did not have time."
She acknowledged the falsification prevented other staff from knowing the resident missed treatments. "Documenting Resident 2's RNS was complete when it was not meant that Resident 2 was not getting the care and services ordered by Resident 2's physician and cannot make up for the loss in treatment," she told inspectors.
A registered nurse at the facility confirmed that documenting completed treatments that weren't performed constituted "willful falsification of medical records." Staff are supposed to inform licensed nurses when treatments aren't completed, she said.
The missed therapy could have serious consequences for someone with the resident's conditions. The Director of Staffing Development warned that without the ordered range-of-motion exercises, the resident "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 told inspectors that skipping the therapy could cause the resident to "become contracted, be in pain, and have a loss of function."
The registered nurse said missing care "could lead to a decline in Resident 2's health and Resident 2's health would not improve."
Federal inspectors observed RNA 5 providing therapy during their visit, watching her perform the abbreviated version she admitted to regularly giving. She demonstrated leg extensions, flexion, lateral movement, ankle rotation, and other exercises, but only completed one set of 10 repetitions instead of the three sets of 20 ordered by the physician.
The facility's own policy states that residents should receive restorative nursing care to "help promote optimal safety and independence" and maintain their "dignity, independence and self-esteem."
The falsified records affected a resident whose medical conditions already severely limit independence and communication abilities, creating what inspectors called a risk that accurate information about the person's care "could affect Resident 2's care and result in ROM decline."
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MONROVIA GARDENS HEALTHCARE CENTER in MONROVIA, CA was cited for violations during a health inspection on February 26, 2025.
The physician ordered 20 repetitions, three sets each, five days per week.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.