Monrovia Post Acute

Based on interview and record review, the facility failed to report an allegation of abuse for one of two sampled residents (Resident 8) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Investigation and Reporting, dated 7/2017.This failure resulted in the delay of notification to the Department and had the potential to result in Resident 8 to be subjected to abuse while at the facilityFindings:During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 7/5/2025, and readmitted the resident on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pulmonary edema (a long-term condition where fluid accumulates in the lungs), and toxic encephalopathy (a brain disorder caused by exposure to poisonous substances, leading to symptoms such as confusion, memory loss, and changes in personality).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 7/12/2025, the MDS indicated Resident 8 was mild impaired in cognitive skills (ability to make daily decisions).

The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. Resident 8 required partial/moderate assistance (helper does less than half the effort.

Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for personal hygiene.During a review of Resident 8's Progress Notes (PN), dated 8/17/2025, the PN indicated the Social Service Director (SSD) interviewed Resident 8, and Resident 8 stated a CNA wearing green scrubs (CNA 2) told Resident 8 to shut up and hit Resident 8 on the mouth during 8/15/2025 night shift (from 8/15/2025 at 11 p.m. to 8/16/2025 at 7 a.m.).

During a phone interview on 8/18/2025 at 1:55 PM with CNA 2, CNA 2 stated CNA 2 did not report when Resident 8 told CNA 2 You are hitting me during 8/15/2025 night shift when CNA 2 was providing care to Resident 8. CNA 2 stated CNA 2 should report to charge nurse, administrator, local law enforcement immediately when an allegation of abuse was made by residents.

During an interview on 8/18/2025 at 3:52 PM with the DON, the DON stated the staff should report to California Department of Public Health (CDPH), local law enforcement, and ombudsman within two hours when a resident say's, You tried to hit me.

During an interview on 8/19/2025 at 3:35 PM with the Administrator, the Administrator stated, the Administrator, did not receive an allegation of abuse report from CNA 2 during 8/15/2025 night shift (11pm to 7am).During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/2017, the P&P indicated, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a.

Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; ort.

Twenty-four (24) hours, if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/20/2025 at 3:51 pm, the Director of Nursing (DON) stated staff should always offer to assist and help residents out of bed into a chair for meals as ordered by the physician.

The DON stated staff must always offer to assist a resident out of bed to chair for meals if ordered by the physician and if appropriate for out of bed activities despite history of refusals.

The DON stated it was important staff assisted residents to a chair for meals because it was an optimal positioning for eating, improved mobility, and improved a resident's level of independence.

During a review of the facility's undated Policy and Procedure (P/P) titled Activities of Daily Living (ADLs), Supporting, the P/P indicated residents were provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.

The P/P indicated appropriate care and services were provided for residents who were unable to carry out ADLs independently, with the consent of the resident, and in according with the plan of care, including appropriate support and assistance with mobility and dining.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

indicated the facility helped residents contact specialty providers as needed based on health recommendations.

The P/P indicated the facility would assist in scheduling appointments and arranging necessary transportation for residents to ensure they can attend their appointments.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting, oral, and personal hygiene.

During a review of Resident 1's Progress Notes (PN), dated 8/19/2025, the PN indicated facility staff failed to document an assessment of Resident 1's skin wounds from 7/5/2025 to 7/18/2025.

During a concurrent interview and record review on 8/14/2025, at 2:29 PM with the Treatment Nurse (TN), Resident 1's medical record was reviewed Resident 1's medical record failed to indicate a Weekly Wound Note was documented from 7/5/2025 - 7/18/2025.

The TN confirmed Resident 1 was readmitted to the facility on [DATE] with multiple pressure injuries and Moisture-Associated Skin Damage (MASD, a condition where prolonged exposure to moisture, such as urine, sweat, or wound exudate, leads to skin breakdown and irritation) to Resident 1's buttock.

The TN stated the TN was responsible for completing a weekly wound note for Resident 1.

The TN stated the TN missed documenting Resident 1's weekly wound note.

The TN stated the purpose of the weekly wound note was to track the progress or decline of Resident 1's skin conditions.

During a review of the facility's undated, policy and procedure (P&P) titled, Wound Prevention, the P&P indicated, .Weekly skin checks will be conducted by the licensed nurse.

This will be documented in the resident's Electronic Medical Record (EMR).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting, oral, and personal hygiene.

During a review of Resident 1's Order Summary Report (OSR) dated 8/18/2024, the OSR indicated Resident 1 had a medication order for Morphine Sulfate (a medication used to treat pain) Oral Tablet 15 milligram (MG, a unit of measurement) Give 1 tablet by mouth every 12 hours for pain management.

The medication order started on 7/4/2025.During a concurrent interview and record review on 8/18/2025 at 11 AM with The Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), for August 2025, was reviewed.

The MAR indicated Resident 1 did not receive Resident 1's ordered Morphine Sulfate 15 MG on 8/3/2025 at 6 AM and 6 PM and on 8/4/2025 at 6 AM.

The DON confirmed Resident 1 was on Morphine Sulfate for pain management.

The DON confirmed Resident 1's Morphine Sulfate supply ran out on 8/2/2025 and that Resident 1 missed her 2 doses on 8/3/2025 and one dose on 8/4/2025.

The DON stated the medication ran out because Resident 1's ordering physician had not signed for the morphine.During a telephone interview on 8/18/2025 at 11:20 AM with the facility's contracted Pharmacist (Pharm), the Pharm stated the refill request for Resident 1's Morphine Sulfate 15 mg was not refilled until 8/4/2025.

The Pharm stated the pharmacy did not start the process to refill the request for refill until 8/3/2025.

The Pharm stated the refill request for Resident 1's Morphine Sulfate should have been refilled two days prior to the supply running out at the facility.

During a review of the facility's Policy and Procedure (P&P) titled, Medication Orders and Receipt Record, revised April 2007, the P&P indicated, .Medications should be ordered in advance, based on the dispensing pharmacy's required lead time.

During a review of the facility's undated P&P titled, Transmitting Medication Orders the P&P indicated, .Reorder these medications when a three to five-day supply remains in the medication storage.Federal Schedule II controlled substances:a.

Inform the pharmacy when a five-day supply remains in the medication storage.

There is no authorized automatic refill available for scheduled II controlled substancesb.

Upon nurses reorder request, the Pharmacy then is required by law to communicate and obtain a prescription from the physician before any new or reordered Schedule II medication may be dispensed.c.

Therefore it is imperative that the facility reorder these medications at least 5 days ahead of running out of medication.d.

Nurse must call and speak to a pharmacist if a reorder is urgently needed to expedite the process.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

During an interview and record review on 8/20/2025 at 3:51 pm, the Director of Nursing (DON) stated the facility provided rehabilitation services which included PT, OT, and ST per physician's orders.

The DON stated she reviewed Resident 10's clinical record with the Medical Records Department and confirmed they were unable to locate any ST evaluations as ordered by the physician on or around 5/1/2025.

The DON stated ST evaluations and therapy screens were not the same.

The DON stated ST evaluations, not therapy screens, must be done by ST if ordered by the physician.

The DON stated it was important Resident 10 received an ST evaluation as ordered by the physician to ensure Resident 10 received the proper care and services he needed because he had difficulty communicating and was on a modified diet.

During a review of the facility's Policy and Procedure (P/P) titled, Specialized Rehabilitative Services, revised 12/2009, the P/P indicated the facility provided specialized rehabilitative services, which included PT, ST, and OT.

The P/P indicated therapy services were provided upon the written order of the resident's attending physician.

During a review of the facility's Job Description titled Speech Pathologist, revised 11/1/2024, the Job Description indicated the Speech Pathologist was responsible for assessing, diagnosing, and treatment residents with communication, cognitive, and swallowing disorders.

The Job Description indicated duties and responsibilities of the Speech Pathologist included evaluating the resident's swallowing, speech, and language difficulties through detailed assessments and diagnostic tools.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Post Acute

1220 E.

Huntington Drive Duarte, CA 91010

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited MONROVIA POST ACUTE in DUARTE, CA for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-08-20.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of MONROVIA POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-12.