Monrovia Post Acute: Missing Property Complaint Ignored - CA
The resident, identified in inspection records only as Resident 1, was admitted to the facility on August 19, 2024, with diagnoses including acute embolism, deep vein thrombosis in her lower extremities, morbid obesity, and a fall. According to her most recent assessment, dated February 23, 2025, she had no cognitive impairments. She was fully capable of making her own decisions and communicating her needs. She needed help with bathing, dressing her lower body, and toileting hygiene, but her mind was clear.
When she noticed two cord holders missing, small devices used to bundle and secure power cords, she did what she was supposed to do. She told the certified nursing assistant assigned to her care.
That is where the process ended.
The nursing assistant, referred to in inspection documents as CNA 1, confirmed during an interview on the morning of March 20, 2025, that Resident 1 had in fact reported the missing items. CNA 1 also confirmed that she had not passed that information along to any supervisor. No explanation was offered for why.
Federal inspectors reviewed the facility's Theft and Loss Report Log for January and February 2025. The log was empty. Not a single missing item had been recorded during those two months. The Director of Nursing, reviewing the log alongside inspectors that afternoon, acknowledged that any report of missing belongings should have appeared there.
Later the same day, the Director of Nursing described how the system was supposed to work: a resident tells a CNA, the CNA tells a supervisor, the supervisor contacts social services. A straightforward chain. In this case, the chain broke at the first link and stayed broken.
The facility's own written policy, last revised in August 2022, states that resident belongings are to be treated with respect by staff, regardless of their perceived value. Cord holders are not expensive. They are not irreplaceable in any financial sense. But that framing, the idea that something small enough to dismiss is still something worth protecting, is precisely what the policy exists to address.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that the failure had the potential for Resident 1 to feel unheard and disrespected. That language is careful and measured in the way regulatory language tends to be. What it describes is a woman who reported a problem, was told implicitly by the silence that followed that it did not matter, and then sat with that silence for however long it took for a federal inspection to surface what had happened.
The inspection was conducted on March 20, 2025, at Monrovia Post Acute, located at 1220 East Huntington Drive in Duarte.
The cord holders have not been mentioned as recovered.
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 3, 2026 · Our methodology
MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on March 20, 2025.
According to her most recent assessment, dated February 23, 2025, she had no cognitive impairments.
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.