Monrovia Post Acute: Medication Tracking Failures - CA
A complaint inspection completed October 27, 2025 found that the facility's pharmacy delivery receipts for at least three residents carried no signatures, no dates, and no timestamps from the nurses who received the medications. The receipts, reviewed by inspectors as of July 14, 2025, were effectively blank on every field that would establish who took custody of the drugs and when.
One of those residents was Resident 7, who had been prescribed Doxycycline Hyclate 100 mg tablets twice daily for facial redness, a 60-day course ordered July 17, 2025. The resident's health and physical examination from August 22, 2025 documented that Resident 7 had the capacity to understand and make their own decisions. That detail matters: this was not a resident unable to track their own care. And still, the basic paperwork confirming their medication had actually arrived, in the right quantity, received by an accountable person, did not exist.
Residents 1 and 6 had the same problem on the same receipt log.
A registered nurse at the facility, identified in the inspection report as RN 3, confirmed what inspectors found during an interview the afternoon of October 27. RN 3 stated plainly that there was no date, time, or signature of a licensed nurse on the delivery receipts for any of the three residents. RN 3 also described exactly what should have happened: the nurse receiving the medications signs the receipt, writes the date and time, and places a copy in the resident's record.
The facility's own policy, a document on medication orders and receipt records that carried no date itself, spelled out the same requirements. The receipt record must contain the date and quantity received, and the name and title of the person receiving the order.
A separate interview four days earlier, on October 23, with a treatment nurse identified as Treatment Nurse 2, reinforced how well-understood this procedure was inside the building. Every medication received from the pharmacy, TN 2 said, should arrive with a receipt that includes a signature, the date, and the time of delivery. The expectation was not ambiguous. The staff could describe it accurately when asked. The receipts still went unsigned.
What the missing signatures leave unresolved is basic: there is no verified record of whether medications for Residents 1, 6, and 7 were received at all, received on time, or received in the quantities ordered. A signature and timestamp are not bureaucratic formalities. They are the mechanism by which a facility can confirm that a resident's medication supply is intact and accounted for. Without them, a gap in a resident's treatment, a delay in delivery, a short count, any of it could pass without documentation to flag it.
For Resident 7, whose doxycycline course ran 60 days starting in mid-July, the question of whether every refill arrived when it should have is one the facility's records cannot answer.
Inspectors rated the violation at a level of minimal harm or potential for actual harm, affecting some residents. The finding fell under F0755, which covers the safe and accurate provision of medications.
The facility's own unsigned policy document sat in the background of all of it, a set of requirements with no date attached, describing a standard the staff understood and the receipts did not reflect.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-10-27 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on October 27, 2025.
The receipts, reviewed by inspectors as of July 14, 2025, were effectively blank on every field that would establish who took custody of the drugs and when.
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.