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Complaint Investigation

Monrovia Post Acute

May 15, 2025 · Duarte, CA · 1220 E. Huntington Drive
Citations 4
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 May 15, 2025.

Found 4 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

FF641
Minimal harm or Records (MAR), dated 4/1/25 to 4/30/25, and MAR, dated 5/1/25 to 5/31/25 were reviewed. The MDS Few LVN 3 then showed a Neurology (the branch of medicine that deals with diagnosis and treatment of disorder affected

During a review of Resident 2's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make her own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) three times a day for Parkinson's disease.

During a review of Resident's 2's MDS) dated [DATE], the MDS indicated Resident 2 was cognitively severely impaired (mental action or process of acquiring knowledge and understanding) for daily decision making.

During a concurrent observation and interview on 5/12/25 at 11:57 a.m. with Resident 2, Resident 2 was sitting up in bed alert and oriented.

When Resident 2 raised Resident 2's arms, noticeable tremors were present in both Resident 2's hands and arms. Resident 2 stated, Excuse me shaking, I have Parkinson's.

During a review of Resident 2's medical record on 5/12/25, no care plan for a diagnosis of Parkinson's disease and use of Sinemet was found.

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 05/15/2025

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 History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make her own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) three times a day for Parkinson's disease.

During a review of Resident's 2's MDS) dated [DATE], the MDS indicated Resident 2 was cognitively severely impaired (mental action or process of acquiring knowledge and understanding) for daily decision making.

During a concurrent observation and interview on 5/12/25 at 11:57 a.m. with Resident 2, Resident 2 was sitting up in bed alert and oriented.

When Resident 2 raised Resident 2's arms, noticeable tremors were present in both Resident 2's hands and arms. Resident 2 stated, Excuse me shaking, I have Parkinson's.

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 05/15/2025

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 History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) three times a day for Parkinson's disease.

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 05/15/2025

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 History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) three times a day for Parkinson's disease.

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 05/15/2025

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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