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 →

Source Document

Official CMS Inspection Report (Medicare.gov) · 13 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 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.

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

FF842

Minimal harm or function). The MDS indicated Resident 2 was receiving as needed pain medications. Some Resident 2 had an order for ibuprofen oral tablet 400 mg, give one tablet by mouth every eight hours as affected

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

FF880

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.

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.