DUARTE, CA - Federal inspectors cited Monrovia Post Acute for multiple care violations, including inappropriate pain management that left a resident with severe, uncontrolled pain and falsified medical documentation.
Severe Pain Left Untreated with Wrong Medication
The most serious violation occurred when a licensed vocational nurse administered inappropriate medication to a resident experiencing severe pain. On March 6, 2025, inspectors observed a resident with diabetes, chronic kidney disease, and Parkinson's disease who reported 9 out of 10 pain intensity.
Despite the resident's severe pain level, the nurse administered only Tylenol at 1:50 PM - a medication typically reserved for mild pain rated 1 to 3 out of 10. The nurse then falsely documented the resident's pain score as 3 out of 10 when the actual level was 9 out of 10.
During the inspection, the resident told investigators: "I want to die I'm in so much pain." The resident was observed shaking, covered with blankets, and reported feeling cold and dizzy. The resident's Parkinson's symptoms had flared due to stress from the uncontrolled pain.
Nurse Admits to Protocol Violations
When questioned by inspectors, the nurse acknowledged multiple protocol violations. The nurse admitted to giving Tylenol "without asking Resident 3 how much pain Resident 3 had" and stated "Giving something was better than giving nothing."
The nurse further acknowledged that documenting incorrect pain scores was "inaccurate documentation and put Resident 3 in more pain than Resident 3 need to be and could make Resident 3's pain out of control."
Medical Significance of Pain Management Failures
Pain assessment forms a critical component of appropriate medical care in nursing facilities. When pain reaches 7 to 10 out of 10, it typically requires stronger medications such as opioid-based treatments like Norco, which the resident had received earlier in the morning.
Tylenol (acetaminophen) provides effective relief only for mild to moderate pain. For severe pain, it offers minimal therapeutic benefit and can delay appropriate treatment. The resident had been prescribed Norco for severe pain episodes, but medication timing restrictions prevented its administration until 6 PM due to eight-hour dosing intervals.
Accurate pain documentation serves multiple critical functions: it ensures appropriate medication selection, tracks treatment effectiveness, facilitates physician communication, and provides legal protection for care decisions. Falsified pain scores compromise all these safeguards.
Infection Control Protocol Failures
Inspectors also documented infection control violations involving two residents on Enhanced Barrier Precautions. These protocols require strict hand hygiene to prevent transmission of multidrug-resistant organisms.
On March 6, inspectors observed a certified nursing assistant enter a resident's room with an active foot infection and diabetic ulcer without performing required hand hygiene. The CNA checked the resident's blood pressure and exited without hand sanitization, despite clear signage requiring these precautions.
A second CNA similarly failed to follow hand hygiene protocols when entering another resident's room designated for Enhanced Barrier Precautions. When questioned, this CNA acknowledged: "I should have sanitized my hands for EBP before and after entering Resident 10's room."
Required Pain Management Protocols
Federal nursing home regulations require comprehensive pain assessment before medication administration. The facility's Director of Nursing confirmed that licensed nurses must "assess residents' pain score before giving pain medication because staff had to give appropriate medication based on the pain score."
When residents report severe pain and current medications prove inadequate, protocols require nurses to contact the resident's primary care physician for additional orders rather than administering inappropriate alternatives.
Consequences and Standards
The Director of Nursing stated that providing inappropriate pain medication and false documentation "could end up with more or uncontrolled pain" for residents. The facility's own policies emphasize that medical record documentation must be "objective, complete, and accurate" to facilitate proper communication among the care team.
These violations occurred during a complaint-based inspection on March 6, 2025. The Centers for Medicare & Medicaid Services classified both violations as causing "minimal harm or potential for actual harm" but noted they affected multiple residents regarding infection control protocols.
The inspection report indicates Monrovia Post Acute must submit a plan of correction addressing these deficiencies. The facility is located at 1220 E. Huntington Drive in Duarte, California.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-03-06 including all violations, facility responses, and corrective action plans.
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