Complaint Investigation

Monrovia Post Acute

July 22, 2024 · Duarte, CA · 1220 E. Huntington Drive

Citations 2

CMS Rating 3/5

Beds 82

Provider ID 055259

Healthcare Facility

Monrovia Post Acute

Duarte, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 9 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

MONROVIA POST ACUTE in DUARTE, CA — inspection on July 22, 2024.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF657

Actual harm drug (medication that affects behavior, mood, thoughts, or perception) use, unawareness of safety needs, Few information on past falls and attempt to determine cause of falls, record possible root causes, and affected

During a review of Resident 1's Fall Risk Evaluation, dated 6/7/2024, the Fall Risk Evaluation indicated, Resident 1 was at high risk for falls.

During a review of Resident 1's History and Physical Examination (H&P), dated 6/8/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.

055259

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055259 B.

Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

FF689

Minimal harm or think and process information). The MDS indicated, Resident 1 normally used a walker (a device that gives Few for toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, affected

During a review of Resident 1's Fall Risk Evaluation, dated 6/7/2024, the Fall Risk Evaluation indicated, Resident 1 was at high risk for falls.

During a review of Resident 1's History and Physical Examination (H&P), dated 6/8/2024, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.

During a review of Resident 1's untitled care plan (CP), initiated on 6/7/2024, and revised on 6/9/2024, the CP indicated, Resident 1 was at high risk for falls due to confusion, gait/balance problems, psychoactive drug (medication that affects behavior, mood, thoughts, or perception) use, unawareness of safety needs, and history of falls.

The CP interventions included for staff to anticipate and meet Resident 1's needs, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter/remove any potential causes of falls if possible.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

055259

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055259 B.

Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUARTE, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MONROVIA POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.