Monrovia Post Acute
MONROVIA POST ACUTE in DUARTE, CA — inspection on March 20, 2025.
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
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1 had no impairments in cognitive skills (ability to make daily decisions).
The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing, lower body dressing, and toileting hygiene.
During an interview on 3/20/2025 at 10:08 a.m. with Resident 1, Resident 1 stated the facility conducted a care plan meeting with Resident 1 on 2/27/2025 at Resident 1's bedside. Resident 1 stated the facility staff inacuratly documented on Resident 1's medical record that the activities assistant was present at the care plan meeting.
During a concurrent interview and record review on 3/20/2025 at 12:49 p.m. with the Activities Assistant (AA), Resident 1's Multidisciplinary Care Conference, dated 2/27/2025, was reviewed. Resident 1's Multidisciplinary Care Conference indicated the AA attended the quarterly care conference on 2/27/2025.
The AA stated the AA did not attend the care conference.
During a concurrent interview and record review on 3/20/2025 at 2:00 p.m. with the Director of Nursing (DON), Resident 1's Multidisciplinary Care Conference, dated 2/27/2025, was reviewed. Resident 1's Multidisciplinary Care Conference indicated AA attended the quarterly care conference on 2/27/2025 along with Dietary, the MDS nurse, the Social Worker, and Resident 1.
The DON stated it was the DON's expectation that the different disciplines meet at the same time to be on the same page.
During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
055259
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1 had no impairments in cognitive skills (ability to make daily decisions).
The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing, lower body dressing, and toileting hygiene.
During an interview on 3/20/2025 at 10:08 a.m. with Resident 1, Resident 1 stated Resident 1 was missing two cord holders (device used to strap power cords together). Resident 1 stated Resident 1 reported the missing items to Certified Nursing Assistant (CNA) 1.
During an interview on 3/20/2025 at 11:50 a.m. with CNA 1, CNA 1 stated Resident 1 informed CNA 1 that Resident 1 was missing two cord holders. CNA 1 stated CNA 1 did not report Resident 1's missing items to CNA 1's supervisors.
During a concurrent interview and record review on 3/20/2025 at 1:45 p.m. with the Director of Nursing (DON), the facility's Theft and Loss Report Log, dated January 2025 and February 2025, were reviewed.
The Theft and Loss Report Log indicated no theft or loss were reported.
The DON stated the log should list any reports of missing items.
During an interview on 3/20/2025 at 2:55 p.m. with the DON, the DON stated if residents (in general) report missing personal belongings to CNA's (in general), the CNA should report the missing items to their immediate supervisor who should in turn report to the facility's social services.
During a review of the facility's Policy and Procedure (P&P) titled, Personal Property, revised August 2022, the P&P indicated, .Resident belongings are treated with respect by facility staff, regardless of perceived value.
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 03/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Monrovia Post Acute 1220 E.
Huntington Drive Duarte, CA 91010