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Complaint Investigation

Monrovia Gardens Healthcare Center

January 24, 2025 · Monrovia, CA · 615 W. Duarte Rd.
Citations 2
CMS Rating 1/5
Beds 96
Provider ID 055367
Healthcare Facility
Monrovia Gardens Healthcare Center
Monrovia, CA  ·  View full profile →
Inspection Summary

MONROVIA GARDENS HEALTHCARE CENTER in MONROVIA, CA — inspection on January 24, 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

FF656
Actual harm high blood pressure), and hypoglycemic agents (medications to treat high blood sugar), urinary incontinence Few predisposing conditions (conditions that give way to the development of disease). affected

During a review of Resident 12's first untitled care plan (CP), initiated on 7/14/2023, and revised on 8/2/2024, the CP indicated Resident 12 was at risk for falls related to limited mobility, balance problems, confusion, poor safety awareness, history of multiple falls, and use of psychotropics (medications that affect the mind, emotions, and behavior) and diuretic (medication that causes the kidneys to make more urine).

The CP interventions included to anticipate and meet Resident 12's needs, follow facility's fall protocol, and provide a safe environment.

055367

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 055367 B.

Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Gardens Healthcare Center 615 W.

Duarte Rd.

Monrovia, CA 91016

During a review of Resident 12's Admission Record (AR), the AR indicated the facility admitted Resident 12 to the facility on [DATE], with diagnoses that included congested heart failure (CHF - a heart condition that develops when the heart does not pump enough blood for the body's needs), type 2 diabetes (DM2 - a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (ESRD - a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).

During a review of Resident 12's first untitled care plan (CP), initiated on 7/14/2023, and revised on 8/2/2024, the CP indicated Resident 12 was at risk for falls related to limited mobility, balance problems, confusion, poor safety awareness, history of multiple falls, and use of psychotropics (medications that affect the mind, emotions, and behavior) and diuretic (medication that causes the kidneys to make more urine).

The CP interventions included to anticipate and meet Resident 12's needs, follow facility's fall protocol, and provide a safe environment.

During a review of Resident 12's Fall Risk Assessment (FRA), dated 4/15/2024, the FRA indicated Resident 12 was at high risk for falls due to history of falls, use of psychotropics, antihypertensive (medication to treat high blood pressure), and hypoglycemic agents (medications to treat high blood sugar), urinary incontinence (inability to control the flow of urine from the bladder), agitated (irritable/unpleasant) behavior and predisposing conditions (conditions that give way to the development of disease).

During a review of Resident 12's History and Physical Examination (H&P), dated 4/16/2024, the H&P indicated Resident 12 did not have the capacity to understand and make decisions.

055367

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 055367 B.

Wing 01/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monrovia Gardens Healthcare Center 615 W.

Duarte Rd.

Monrovia, CA 91016

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 MONROVIA, 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 GARDENS HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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