Monrovia Post Acute: Falsified Care Records Found - CA
The resident, identified in inspection records only as Resident 1, was admitted to the facility on August 19, 2024, following diagnoses that included blood clots in the deep veins of her lower extremities and morbid obesity. She had no cognitive impairments, according to her own assessment records. She knew what had happened at her care meeting, and she knew what the paperwork said afterward. The two did not match.
The facility held a quarterly care conference at Resident 1's bedside on February 27, 2025. These meetings are where staff, residents, and family members are supposed to come together to review a resident's care plan and progress. The official record of that meeting, a document called a Multidisciplinary Care Conference form, listed six attendees: the dietary department, the MDS nurse, the social worker, Resident 1 herself, and the activities assistant.
The activities assistant was not there.
When inspectors sat down with the activities assistant on March 20, 2025, and showed her the form with her name on it, she was direct. She did not attend the care conference, she told them. The form said otherwise.
Resident 1 had already said the same thing that morning. In an interview at 10:08 a.m., she told inspectors that staff had inaccurately documented the activities assistant as present. She noticed. She said so. It took inspectors asking the assistant directly to get the facility's own staff to confirm what the resident had been saying.
The Director of Nursing reviewed the same document with inspectors that afternoon. Her response was not to address the inaccuracy directly but to describe what she expected care conferences to look like: different disciplines meeting at the same time, she said, so everyone could be on the same page. The record showed that did not happen, at least not with the activities assistant. Whether the DON knew the form was wrong before inspectors arrived, the report does not say.
The facility's own internal policy, last revised in July 2017, states that documentation in the medical record must be objective, complete, and accurate. The care conference form was none of those things. It placed a staff member in a room she was not in, on a date she was not there, for a meeting about a resident's care.
Federal inspectors cited the facility for a documentation violation and rated the level of harm as minimal, affecting a small number of residents. That rating reflects the regulatory floor, not necessarily what it means to the person whose record now contains information she knows to be false.
A medical record is the foundation of a resident's care. It tells the next nurse, the next doctor, the next inspector what happened and who was responsible. When a care conference form shows that a full interdisciplinary team reviewed a resident's condition, and one of the listed attendees was not actually present, the record does not accurately reflect who was involved in that resident's care decisions.
Resident 1 raised the issue herself. She had the cognitive capacity to do so, and she did. The question the inspection report leaves open is how many residents in similar situations do not.
Monrovia Post Acute is a post-acute and rehabilitation facility in Duarte, in Los Angeles County. The inspection was conducted on March 20, 2025. Resident 1 remained at the facility at the time, her medical record still containing a care conference form that lists a staff member who confirmed, under questioning, that she was never in the room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-03-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 10, 2026 · Our methodology
MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on March 20, 2025.
She had no cognitive impairments, according to her own assessment records.
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.