Monrovia Gardens: Resident Left in Soiled Brief 24 Hours - CA
The resident had been lying in urine-soaked sheets and a soiled brief for 24 hours at Monrovia Gardens Healthcare Center, despite facility policy requiring staff to check residents every two hours.
Federal inspectors discovered the neglect during a complaint investigation in August. The resident, identified as Resident 4 in the report, suffers from multiple conditions including the inability to produce voiced sound and generalized anxiety disorder.
When inspectors observed the resident's room at 4:30 pm on August 29, they found a certified nursing assistant moving the resident to their right side. The brief showed yellowish discoloration on the lower portion and contained brown-colored stool of medium size.
Less than an hour later, at 5:14 pm, the same nursing assistant told inspectors the resident's wet brief was yellow in color. The bed sheet smelled of urine, the assistant confirmed.
That's when the resident used their tablet to communicate the extent of their abandonment.
The nursing assistant later admitted to inspectors that the left side of the resident's bed sheet and gown were wet. The resident's "whole brief was wet," the assistant said.
The resident's care plan, initiated in October 2023 and revised as recently as July 2025, specifically identified them as incontinent with both bowel and bladder due to impaired mobility and inability to alert staff. The plan noted the resident was at risk for infection and skin breakdown.
Staff were supposed to check the resident for bladder incontinence at least every two hours and increase frequency as needed. They were instructed to keep the resident's call light within reach and answer promptly, monitor for redness or skin breakdown, and report concerns to the medical doctor.
The resident's medical assessment showed intact cognitive ability despite their inability to speak. They experienced depression or hopelessness seven to 11 days per week. The resident required substantial assistance with personal hygiene and bathing, and was completely dependent on staff for toileting and transfers between bed and chair.
The resident also suffered from hereditary and idiopathic neuropathy, a condition involving damage to the peripheral nervous system.
During interviews with inspectors, the facility's Director of Nursing acknowledged that residents' briefs should be checked and changed every two hours and as needed to ensure they were "not soaked" and "not uncomfortable."
The director explained that being left wet could lead to psychosocial issues for residents. Hair brushing, she noted, was part of daily care that should occur after showers, during morning care, and as needed. Without proper grooming, hair could become matted and tangled, potentially requiring cutting.
"Matted hair could cause discomfort," the director told inspectors. "Having matted hair could make a resident feel like they are not cared for."
The facility's own policy, revised in March 2018, states that "residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."
The resident's care plan goals specifically indicated they should be kept "clean, dry, and odor free daily for three months."
Instead, this resident with multiple disabilities and intact cognition was forced to endure lying in their own waste for an entire day. Their only recourse was typing a plea for help on a tablet when inspectors finally arrived.
The violation represents a failure of the most basic caregiving responsibilities. A resident who cannot speak or move independently was left to suffer in conditions that facility leadership acknowledged could cause infection, skin breakdown, and psychological harm.
The inspection found the facility violated federal regulations requiring residents receive necessary services to maintain personal hygiene and be free from neglect.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Gardens Healthcare Center from 2025-09-03 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 GARDENS HEALTHCARE CENTER in MONROVIA, CA was cited for violations during a health inspection on September 3, 2025.
Federal inspectors discovered the neglect during a complaint investigation in August.
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.