Monrovia Post Acute

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.

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

During an interview on 8/20/2025 at 3:51 pm, the Director of Nursing (DON)

chair for meals if ordered by the physician and if appropriate for out of bed activities despite history

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.

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

During a concurrent interview and record review on 8/20/2025 at 3:51 pm, the Director of Nursing (DON) stated the charge nurse or RN supervisor was responsible for accepting a resident's paperwork, implementing new physician orders and recommendations received, updating the progress notes, scheduling necessary follow up appointments, and informing the resident's primary physician of recommendations and plan of care when a resident returned to the facility from a consultation appointment.

The DON reviewed Resident 10's clinical record and confirmed Resident 10 had a physician's order, dated 3/20/2025, for Resident 10 to receive cortisone injections to the left hip and left knee with IR.

The DON stated Resident 10 never received cortisone injections to the left hip and left knee as ordered because the RN who entered the order forgot to request insurance authorization.

The DON stated Resident 10's follow-up appointment for cortisone injections should have been scheduled, and PT should have been ordered as recommended by the Orthopedic physician but was not.

The DON stated it was important for staff to implement consultation recommendations for continuity of care and to ensure the residents received the treatments and services they needed.

During a review of the facility's job description titled, RN Supervisor, revised 11/1/2024, the job description indicated duties and responsibilities of the RN Supervisor included ordering diagnostic and therapeutic services and communicating effectively with residents physicians and other healthcare team members regarding care needs, changes in condition, and ongoing treatments.

During a review of the facility's job description titled, Charge Nurse - Licensed Vocational Nurse/Licensed Practical Nurse, revised 11/1/2024, the job description indicated duties and responsibilities of the charge nurse included completion of requisitions and arrangement for diagnostic and therapeutic services, as ordered by the physician, and in accordance with the facility's established procedures, and scheduling of tests and preps as needed.

During a review of the facility's undated Policy and Procedure (P/P) titled Appointments, the P/P 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.

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

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).

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

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.

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

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.

055259 08/20/2025

Monrovia Post Acute 1220 E.

Huntington Drive Duarte, CA 91010

Clerk.