Inspection Report

Monrovia Post Acute: Care Plan Violations - Duarte, CA

November 1, 2025

Duarte, CA

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DUARTE, CA - A recent state inspection at Monrovia Post Acute found the facility failed to properly assess a resident's neurological condition and develop an appropriate care plan for managing Parkinson's disease medication, potentially putting the resident at risk for adverse medication events.

Assessment Documentation Errors Discovered

The May 15, 2025 inspection revealed significant issues with how staff documented and tracked a resident's medical conditions. The resident, who has bipolar disorder, dementia, and Parkinson's disease, was not properly identified as having Parkinson's disease in the facility's official assessment records, despite clear medical evidence of the condition.

During the inspection, the resident was observed sitting up in bed with noticeable tremors in both hands and arms. "Excuse me shaking, I have Parkinson's," the resident told inspectors, clearly aware of their condition.

Medical records showed the resident had been prescribed Sinemet, a combination medication containing levodopa and carbidopa specifically used to treat Parkinson's disease symptoms. The medication was ordered to be given three times daily through a gastrostomy tube. However, the facility's Minimum Data Set (MDS) assessment - a comprehensive evaluation required for all nursing home residents - failed to include Parkinson's disease under the neurological conditions section.

Medication Management and Monitoring Gaps

The inspection uncovered concerning issues with medication continuity and follow-up care. A neurologist had evaluated the resident in January 2025 for tremors and initiated a trial of Levodopa medication. "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," the neurologist documented in consultation notes.

Records showed the Sinemet medication was started on January 27, 2025, then discontinued on May 7, 2025, and restarted the following day on May 8, 2025. However, the facility never contacted the neurologist for follow-up monitoring, despite his specific instructions.

The neurologist told inspectors during a phone interview that he had only seen the resident once and "there was no follow-up by MD 1 because the facility did not contact MD 1 again about Resident 2." He explained that follow-up on the Levodopa trial should have occurred within a day or two after the resident started taking the medication.

Medical Significance and Risk Factors

Accurate assessment and documentation of neurological conditions like Parkinson's disease is critical for resident safety. Sinemet, while effective for managing Parkinson's symptoms, carries significant risks that require careful monitoring. The medication can cause dyskinesia - abnormal, involuntary, and repetitive movements - as well as behavioral disturbances, particularly in residents with existing cognitive impairment.

For residents with dementia, like this individual who was assessed as cognitively severely impaired, the risks are amplified. The combination of Parkinson's disease, bipolar disorder, and dementia creates a complex medical picture requiring specialized attention and regular physician oversight.

When medications like Sinemet are prescribed for neurological conditions, healthcare standards require comprehensive care planning that includes monitoring protocols, potential side effects, and clear communication pathways with specialists. The facility's failure to maintain proper documentation could lead to medication errors, missed adverse reactions, or inappropriate treatment decisions by staff unfamiliar with the resident's complete medical history.

Care Planning Requirements Not Met

Nursing facilities are required to develop comprehensive care plans that address all aspects of a resident's medical needs, including medication management and monitoring. These plans must include specific timetables, measurable actions, and clear protocols for managing complex medications.

In this case, the facility should have established protocols for monitoring the resident's response to Sinemet, documented procedures for communicating with the neurologist, and included Parkinson's disease management strategies in the overall care plan. The absence of these elements left the resident vulnerable to potential complications from both the underlying condition and its treatment.

Licensed Vocational Nurse 3, who was interviewed during the inspection, acknowledged the documentation error and stated that "the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event." The nurse recognized that proper monitoring protocols should have been implemented to watch for adverse side effects.

Additional Issues Identified

The inspection also revealed procedural gaps in assessment practices. Despite having established policies requiring that assessment information consistently reflect progress notes, care plans, and resident observations, the facility failed to follow these protocols. Staff members responsible for assessments are required to have appropriate skills and qualifications and be knowledgeable about residents' conditions and changes in status.

The facility's own policy states that comprehensive assessments must be completed by qualified staff members at designated intervals and should accurately reflect all relevant medical information. The failure to properly document the Parkinson's disease diagnosis represented a breakdown in these fundamental assessment processes.

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

Editorial Standards

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: August 5, 2026 · Our methodology

Quick Answer

MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on May 15, 2025.

During the inspection, the resident was observed sitting up in bed with noticeable tremors in both hands and arms.

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.

Frequently Asked Questions

What happened at MONROVIA POST ACUTE?

During the inspection, the resident was observed sitting up in bed with noticeable tremors in both hands and arms.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in DUARTE, CA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MONROVIA POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 055259.

Has this facility had violations before?

To check MONROVIA POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.