Monrovia Gardens: Call Light Left Broken for Weeks - CA
The call light cord belonging to Resident 4 had been pulled from the wall. When a state inspector visited the room on August 29, 2025, at 5:23 in the afternoon, the cord was still disconnected. LVN 1, the nurse present during the inspection, said it was the first time she had seen the cord pulled out from the wall. That claim did not hold up.
When the Director of Nursing sat down with the inspector on September 3, the account shifted considerably. The DON acknowledged that maintenance staff had already attempted a fix, securing the cord to the wall at some earlier point. Then they realized the repair hadn't held. A replacement part was purchased. It had not been installed. The DON said staff had noticed, in the week before the interview, that the call light was still not secured and still not working. She could not remember the exact date they noticed.
She did not explain why, once staff noticed, nobody installed the part they had already bought.
The call light was also not within reach of Resident 4. The facility's own policy, though it carried no date, described the purpose of the call light system plainly: ensure timely responses to residents' requests and needs. The policy specified the light should be plugged in and functioning at all times, and accessible from the bed, the toilet, the shower, and the floor.
None of those conditions were met for Resident 4.
A call light is not a comfort amenity. For a resident who cannot walk to the door, cannot raise their voice loud enough to be heard in a hallway, or cannot transfer safely without assistance, it is the only mechanism between them and help. A resident who falls in the night, who needs pain medication, who is choking, who has soiled themselves and cannot move, depends on that cord. Without it, they wait. They hope someone comes. Sometimes someone does not.
The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators before inspectors arrived. The facility did not catch and correct this on its own.
What the record shows is a sequence: the cord came out of the wall, maintenance attempted a fix, the fix failed, a replacement part was acquired, the part sat unused, staff noticed the light was still broken, and nothing happened. The DON could not say how long Resident 4 had gone without a functioning call light. The inspector found it still broken during a late-afternoon visit on August 29. The DON's interview was September 3. The part still had not been installed.
CMS rated the harm level as minimal harm or potential for actual harm, and noted few residents were affected. The deficiency did not rise to immediate jeopardy. In the language of federal nursing home enforcement, this registers as a lower-tier finding.
For Resident 4, the classification offers little. The light was broken. Staff knew. The fix was sitting somewhere in the building, uninstalled. And on the evening an inspector came to check, a nurse standing in that room said she had never seen the cord pulled from the wall before.
Monrovia Gardens Healthcare Center is located at 615 W. Duarte Road in Monrovia. The inspection was conducted as a complaint survey. The facility's plan of correction was not included in the inspection documents reviewed.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
MONROVIA GARDENS HEALTHCARE CENTER in MONROVIA, CA was cited for violations during a health inspection on September 3, 2025.
The call light cord belonging to Resident 4 had been pulled from the wall.
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.