Monrovia Post Acute: Missing Items Go Unreported - CA
The resident, admitted in August 2024 with blood clots and morbid obesity, told staff that two cord holders had disappeared from their room. Despite facility policy requiring immediate reporting of missing items, the certified nursing assistant who received the complaint took no action.
"Resident 1 reported the missing items to Certified Nursing Assistant 1," inspectors documented after interviewing the resident on March 20. The resident required substantial help with bathing, dressing and toileting but had no cognitive impairments.
When inspectors questioned CNA 1 later that day, the aide admitted receiving the complaint but confessed to doing nothing about it.
"CNA 1 stated CNA 1 did not report Resident 1's missing items to CNA 1's supervisors," according to the inspection report.
The facility's Director of Nursing confirmed this represented a clear policy violation. During an interview, the DON explained the required chain of reporting: CNAs must immediately notify their supervisor, who then contacts social services.
"If residents report missing personal belongings to CNAs, the CNA should report the missing items to their immediate supervisor who should in turn report to the facility's social services," the DON told inspectors.
The breakdown became more apparent when inspectors examined the facility's official theft and loss logs for January and February 2025. No missing items were recorded during either month.
"The Theft and Loss Report Log indicated no theft or loss were reported," inspectors noted. "The DON stated the log should list any reports of missing items."
The facility's own policy, revised in August 2022, emphasizes respect for all resident belongings: "Resident belongings are treated with respect by facility staff, regardless of perceived value."
Inspectors also discovered documentation problems beyond the missing items case. During their review of four residents' medical records, they found that staff had inaccurately recorded who attended a quarterly care conference for one resident on February 27.
These care conferences serve as crucial planning meetings where staff, residents and family members discuss treatment progress and address concerns. Accurate documentation of attendance helps ensure continuity of care and proper communication among the care team.
The inspection report classified both violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the findings highlight systematic problems with following established procedures designed to protect residents and maintain accurate medical records.
Federal regulations require nursing homes to safeguard resident belongings and maintain medical records according to professional standards. The violations suggest staff either don't understand these requirements or choose not to follow them.
The missing cord holders may seem minor, but they represent something more significant. For residents who depend on facility staff for basic needs, personal belongings often provide comfort and maintain connections to their previous lives. When items disappear and staff ignore reports, it can erode trust and create anxiety.
The resident who reported the missing items had been living at Monrovia Post Acute for seven months at the time of the inspection. Having survived serious medical conditions including blood clots that can be life-threatening, this person deserved to have their concerns taken seriously.
Instead, the aide who received the complaint simply walked away. No investigation occurred. No supervisors were notified. The official logs remained empty, as if nothing had happened.
The documentation errors in the care conference records compound these problems. When medical records contain inaccurate information about who participated in treatment planning, it can affect future care decisions and create confusion among staff members.
Monrovia Post Acute now faces federal scrutiny over these violations. The facility must submit a plan of correction explaining how it will ensure staff properly report missing items and maintain accurate medical records.
For the resident whose cord holders disappeared, the damage extends beyond the missing items themselves. The experience revealed that when residents raise concerns, staff might simply ignore them, leaving problems unresolved and trust broken.
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: 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 POST ACUTE in DUARTE, CA was cited for violations during a health inspection on March 20, 2025.
The resident, admitted in August 2024 with blood clots and morbid obesity, told staff that two cord holders had disappeared from their room.
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.