Monrovia Gardens Healthcare Center
MONROVIA GARDENS HEALTHCARE CENTER in MONROVIA, CA — inspection on February 26, 2025.
Found 5 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.
Inspection Findings
During a review of Resident 2's Progress Notes (PN) dated 1/21/2025 to 2/26/2025, the PN indicated no documentation Resident 2's RHRS was lost.
During an interview on 2/26/2025 at 11:06 am with Resident 2, Resident 2 stated (unidentified) facility staff lost Resident 2's RHRS the week of 1/21/2025 when Resident 2 received the splint. Resident 2 stated Resident 2 told facility staff (unidentified) Resident 2 needed to wear her RHRS, but facility staff did not listen. Resident 2 stated facility staff (unidentified) would not give Resident 2 the RHRS and would not tell Resident 2 where the RHRS was. Resident 2 stated Resident 2 still did not know where the RHRS was at, and that no staff have found it or looked for it.
During a telephone interview on 2/26/2025 at 3:52 pm with the Director of Rehabilitation Services (DOR), the DOR stated the DOR was aware Resident 2 had a RHRS for contractures, but was not aware it was missing.
The DOR stated Resident 2's RHRS put Resident 2's hand in a resting position to keep the hand in a more open and natural position.
The DOR stated without Resident 2's RHRS, Resident 2 could develop further contractures, increased stiffness, discomfort, and pain to the right hand.
During a concurrent interview and record on 2/26/2025at 4:57 pm with Registered Nurse (RN) 2, Resident 2's medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) for 1/2025 and 2/2025 was reviewed. RN 2 stated RN 3 received the order for Resident 2's RHRS on 1/21/2025 when Resident 2 received the RHRS. RN 2 stated the DOR assisted RN 2 on how to write the order for Resident 2's RHRS. RN 2 stated RN 2 saw Resident 2's RHRS on the evening of 1/22/2025 and that was the last time RN 2 saw it. RN 2 stated starting 2/10/2025, Resident 2's MAR for the RHRS indicated 10, which was other and required a PN to indicate why a licensed nurse was documenting other. RN 2 stated all facility staff were supposed to keep track of Resident 2's RHRS by documenting it in Resident 2's RCP form and document in Resident 2's PN when the RHRS was donned and doffed (to take off). RN 2 stated if staff could not find Resident 2's RHRS it was their responsibility to report it missing. RN 2 stated Resident 2's RHRS was supposed to help Resident 2 with pain, movement, and help prevent contractures.
During a review of the facility's P&P titled, Personal Property, revised 8/2022, the P&P indicated resident belongings were treated with respect by facility staff, regardless of perceived value.
The P&P indicated residents' personal belongings and clothing are inventoried and documented upon admission and updated as necessary.
The P&P indicated the facility would promptly investigate any complaints of misappropriation or mistreatment of resident property.
055367 02/26/2025
Monrovia Gardens Healthcare Center 615 W.
Duarte Rd.
Monrovia, CA 91016
During an interview on 2/26/2025at 4:57 pm with Registered Nurse (RN) 2, RN 2 stated (in general) if RNAs did not complete a resident's RNS order in its entirety or at all, they were not supposed to initial they completed the treatment, and were supposed to inform a licensed nurse the treatment was not completed. RN 2 stated documenting a treatment was completed when it was not, was considered willful falsification of medical records. RN 2 stated not delivering care to Resident 2 could lead to a decline in Resident 2's health and Resident 2's health would not improve.
During a review of the facility's P&P titled, Restorative Nursing Services, undated, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.
The P&P indicated, Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence and self-esteem; and d. participating in the development and implementation of his/her plan of care.
055367 02/26/2025
Monrovia Gardens Healthcare Center 615 W.
Duarte Rd.
Monrovia, CA 91016
During a review of the facility's P&P titled, Charting and Documentation, revised 7/2017, the P&P indicated, All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.
The P&P indicated, The medical record should facilitate communication between the interdisciplinary team (IDT- group of health care professionals with various areas of expertise who work together toward goals of their residents) regarding the resident's condition and response to care.
The P&P indicated, Documentation in the medical record would be objective (not opinionated or speculative), complete, and accurate.
During a review of Resident 2's physician order (PO) dated 6/11/2024 the PO indicated Resident 2 to have RNA for bilateral lower extremity (BLE- both legs) active-assisted ROM exercises (AAROM- the joint receives partial assistance from an outside force) daily, five (5) days per week of 20 repetitions, three (3) sets of each exercise or as tolerated by patient.
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 02/26/2025
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 2's physician order (PO) dated 6/11/2024 the PO indicated Resident 2 to have RNA for bilateral lower extremity (BLE- both legs) active-assisted ROM exercises (AAROM- the joint receives partial assistance from an outside force) daily, five (5) days per week of 20 repetitions, three (3) sets of each exercise or as tolerated by patient.
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 02/26/2025
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
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.