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Complaint Investigation

Monrovia Post Acute

March 6, 2025 · Duarte, CA · 1220 E. Huntington Drive
Citations 3
CMS Rating 3/5
Beds 82
Provider ID 055259
Healthcare Facility
Monrovia Post Acute
Duarte, CA  ·  View full profile →
Inspection Summary

MONROVIA POST ACUTE in DUARTE, CA — inspection on March 6, 2025.

Found 3 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.

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Inspection Findings

FF697
Minimal harm or Resident 3 stated Resident 3 was cold, dizzy, and In so much pain. Resident 3 was shaking and stated Few Resident 3's feet hurt, so bad, and was in nine out of 10 pain. Resident 3 stated Resident 3 received pain affected

During a review of Resident 3's medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 3/6/2025, the MAR indicated Resident 3 received Norco oral table 10-325 mg, one tablet via GT on 3/6/2025 at 10:07 am for seven out of 10 pain.

The MAR indicated LVN 4 administered the Norco.

During a review of the same MAR, the MAR indicated Resident 3 received Tylenol oral tablet 325 mg, two tablets via GT at 1:50 pm for three out of 10 pain.

The MAR indicated LVN 4 administered the Tylenol.

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 03/06/2025

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

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 8/19/2024 with diagnoses that included acute embolism (an obstacle or blockage in a blood vessel) and thrombosis (the formation of a blood clot inside a blood vessel) of unspecified deep veins of lower extremity and edema (swelling caused by too much fluid trapped in the body's tissues).

During a review of Resident 2's untitled Care Plan (CP), initiated 8/20/2024, the CP indicated Resident 2 was at risk for pain related to limited mobility.

The CP goals indicated Resident 2 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain.

The CP interventions included to administer Tylenol (a drug used to treat pain), lidocaine (provides numbing relief for pain), and ibuprofen (a drug used to treat pain) as ordered, to evaluate the effectiveness of pain intervention including resident satisfaction with results and the impact on functional ability, and to notify physician if interventions are unsuccessful.

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 03/06/2025

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

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

F-F880 Infection Control, undated, the P&P indicated, Enhanced barrier precautions (EBPs) are used to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents.

Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.

055259

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.


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