Monrovia Post Acute: Parkinson's Drug Given Without Diagnosis - CA
Resident 2 at Monrovia Post Acute received Sinemet, a combination drug used to treat Parkinson's symptoms, three times daily through her feeding tube starting January 27. But her admission record showed diagnoses of only bipolar disorder and dementia. No Parkinson's disease.
When inspectors interviewed the resident on May 12, she was alert and sitting up in bed. Noticeable tremors shook both her hands and arms when she raised them. "Excuse me shaking, I have Parkinson's," she told them.
The resident's medical record contained no care plan addressing a Parkinson's diagnosis or the use of Sinemet.
Licensed Vocational Nurse 3 couldn't explain the discrepancy during a May 14 interview with inspectors. The nurse reviewed the resident's assessment form, which tracks active diagnoses, and confirmed Parkinson's disease was not selected under the neurological conditions section. "I did not know why Parkinson's Disease was not selected," the nurse stated. "I would have to check my notes."
The nurse then showed inspectors a January 27 neurology consultation note that revealed the medication order's origins. The resident had been evaluated for "concern of Parkinsonism due to recent bilateral upper extremity tremor." During that evaluation, the resident said she had been diagnosed with Parkinson's disease previously but couldn't provide details.
The neurologist's findings were "atypical of Idiopathic Parkinson's disease," but he initiated a levodopa trial anyway. The consultation note included a specific warning: "Given that Levodopa may worsen or precipitate behavior disturbances, I discussed with staff to contact me right away if there are any concerns for adverse reactions to Levodopa."
Medication records showed the resident took Sinemet from January 27 through May 7, when it was discontinued. The drug was restarted May 8.
The nurse acknowledged the assessment was wrong. "The diagnosis was not coded in Resident 2's MDS dated [DATE], and the MDS was inaccurate," she told inspectors. She said accurate diagnosis coding was crucial because the resident "could be taking medication that may result in an adverse medication event."
The nurse explained that proper monitoring should have been implemented because Sinemet can cause dyskinesia, described as "abnormal, involuntary, and often repetitive movements."
Federal inspectors also found the facility's consultant pharmacist failed to identify these medication irregularities during required monthly drug reviews. The pharmacist was supposed to flag medications used without adequate indication or monitoring, but missed the Sinemet administration to a resident with no documented Parkinson's diagnosis.
The resident had been deemed cognitively severely impaired and unable to make her own decisions, according to her assessment and a physician evaluation from October 2024.
Facility policy required all medical records to be "objective, complete, and accurate" and stated that documentation should "facilitate communication between the interdisciplinary team regarding the resident's condition and response to care." Another policy mandated that comprehensive care plans be "based on resident assessments and developed by an interdisciplinary team."
The inspection found the facility violated federal requirements for accurate assessments and pharmaceutical oversight. Inspectors classified the violations as causing minimal harm with potential for actual harm.
The discrepancy meant a cognitively impaired resident received a powerful neurological medication for nearly four months based on her own uncertain recollection of a past diagnosis, while her official medical record showed no such condition and no monitoring plan existed for the drug's serious potential side effects.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-05-15 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 May 15, 2025.
But her admission record showed diagnoses of only bipolar disorder and dementia.
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.