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Complaint Investigation

Monrovia Post Acute

March 20, 2025 · 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 →
Inspection Summary

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.

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Inspection Findings

FF557
Minimal harm or care conference (also known as a care plan meeting, is a scheduled meeting where staff, residents, and Few This failure resulted in Resident 1's medical records to contain inaccurate information. affected

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

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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