Monrovia Gardens Healthcare Center
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2021 15 penalties totaling $27,186
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Health Violations by Year
2025 22 violations
Reasonably accommodate the needs and preferences of each resident.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Keep residents' personal and medical records private and confidential.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide safe, appropriate pain management for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure residents have reasonable access to and privacy in their use of communication methods.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024 5 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide and implement an infection prevention and control program.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
2023 24 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure medication error rates are not 5 percent or greater.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide or get specialized rehabilitative services as required for a resident.
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Provide and implement an infection prevention and control program.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2022 41 violations
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
2021 11 violations
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
2020 2 violations
Provide and implement an infection prevention and control program.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
2019 13 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Respond appropriately to all alleged violations.
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
2018 12 violations
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Respond appropriately to all alleged violations.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Honor each resident's preferences, choices, values and beliefs.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Post nurse staffing information every day.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Keep all essential equipment working safely.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2017 13 violations
Let a representative of the State Ombudsman look at a resident's records, if the resident agreed.
Reasonably accommodate the needs and preferences of each resident.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Post nurse staffing information/data on a daily basis.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Keep all essential equipment working safely.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Keep each resident free from physical restraints, unless needed for medical treatment.
Have enough nurses to care for every resident in a way that maximizes the resident's well being.