Monrovia Post Acute: Cortisone Orders Ignored for Months - CA
The injections had been prescribed on March 20, 2025. An orthopedic surgeon examined the resident, identified as Resident 10 in inspection records, and recommended cortisone injections to the left hip and left knee with imaging guidance, continued pain medication, and physical therapy while the resident remained in the facility. A physician's order was entered that same day. Five months passed.
When inspectors reviewed the clinical record on August 20, 2025, there was no documented evidence that Resident 10 had ever received the injections. No follow-up appointment had been scheduled. Physical therapy had never been ordered.
The Director of Nursing told inspectors exactly what had gone wrong: the nurse who entered the order forgot to request insurance authorization. That single administrative step, never taken, was enough to stop the entire course of treatment from happening. The follow-up appointment that should have been scheduled was not. The physical therapy recommendation from the orthopedic surgeon was not converted into an order.
"It was important for staff to implement consultation recommendations for continuity of care and to ensure the residents received the treatments and services they needed," the Director of Nursing told inspectors.
Resident 10 had not received any physical therapy evaluation orders since November 7, 2024. A physical therapist who spoke with inspectors said the resident would benefit from PT services if a physician recommended them and if the resident was willing to participate. The physician had recommended them. Nobody ordered them.
A registered nurse supervisor, identified in the report as RN 3, walked inspectors through the same clinical record during a concurrent interview that morning. She confirmed the orthopedic note from March, confirmed the physician's order for cortisone injections, confirmed the absence of any documentation showing the injections were given, and confirmed no follow-up had been scheduled. She said staff should have called the orthopedic clinic, obtained insurance authorization, and ordered physical therapy, but did not.
"Staff should have called Resident 10's orthopedic clinic to schedule a follow-up appointment for cortisone injections to Resident 10's left hip and left knee with IR, obtained insurance authorization, and ordered PT per physician recommendations, but did not," RN 3 told inspectors.
The facility's own job descriptions, revised as recently as November 2024, spell out what charge nurses and RN supervisors are supposed to do when a resident returns from a consultation appointment: accept the paperwork, implement new physician orders and recommendations, update progress notes, schedule necessary follow-up appointments, and inform the resident's primary physician of the plan of care. The Director of Nursing confirmed all of that to inspectors. She described the same responsibilities in nearly identical terms.
The facility also had a written appointments policy stating it would help residents contact specialty providers, assist in scheduling, and arrange transportation. Resident 10 needed a specialty appointment. Nobody helped schedule it.
The inspection was triggered by a complaint. Inspectors classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The deficiency was cited under the federal requirement that residents receive necessary care and services to maintain their highest practicable well-being.
What the classification does not capture is the texture of what Resident 10 experienced: a surgeon examined the hip and knee, determined cortisone injections were the appropriate intervention, wrote the order, and sent the resident back to the facility expecting the treatment to happen. It did not happen because one nurse did not complete one authorization request, and no one else caught it for five months. The resident remained without the injections, without the physical therapy, and without any documented follow-up while the order sat in the chart.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-08-20 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: October 21, 2026 · Our methodology
MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on August 20, 2025.
The injections had been prescribed on March 20, 2025.
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.