Monrovia Gardens Healthcare Center
Inspection Findings
F-Tag F688
F-F688
Findings:
During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/4/2023 with diagnoses that included conversion disorder with mixed symptom presentation (mental health condition characterized by physical symptoms that cannot be explained by a medical or neurological condition), dysarthria (speech disorder characterized by difficulty in articulating words and producing clear speech due to weakness or poor coordination of the muscles involved in speech production), anarthria (characterized by the complete inability to articulate speech. caused by damage to the brain or nerves that control the muscles involved in speech production, such as the lips, tongue, and vocal cords), and unspecified neuropathy (A condition that involves damage to the peripheral nervous system from injury or disease process).
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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055367 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 1/9/2025, the MDS indicated Resident 2 had moderately impaired cognition (ability to think, remember, and reason). The Level of Harm - Minimal harm or MDS indicated Resident 2 was dependent (helper does ALL the effort or the assistance of 2 or more helpers potential for actual harm is required for the resident to complete the activity) on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfers. The MDS indicated Resident 2 required Residents Affected - Some substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self, personal hygiene, and rolling left and right.
During a review of Resident 2's RNFS for 1/2025 and 2/2025, the RNFS indicated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed Resident 2's RNFS to indicate RNA 2 provided AAROM exercises to Resident 2 as ordered by Resident 2's physician. The RNFS indicated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2's RNFS to indicate RNA 1 provided AAROM exercises to Resident 2. The RNFS indicated on 2/3/2025, 2/5/2025 to 2/7/2025, 2/10/2025, 2/12/2025 to 2/14/2025, 2/18/2025 to 2/21/2025, 2/24/2025, and 2/25/2025, RNA 5 initialed Resident 2's RNFS to indicate RNA 5 provided AAROM exercises to Resident 2 as ordered by the physician.
During a concurrent interview and record review on 2/26/2025 at 1:44 pm with the Director of Staffing Developing (DSD), RNA 1 and RNA 2's timecards and staffing sign-in sheets and Resident 2's RNFS for 1/2025 and 2/2025 were reviewed. The DSD stated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed Resident 2's RNFS indicating RNA 2 provided the RNS, however RNA 2 was not working (on 1/16/2025, 1/30/2025, and 1/31/2025). The DSD stated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2's RNFS indicating RNA 2 provided the RNS, however RNA 1 was not working (on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025). The DSD stated RNA 1 and RNA 2 no longer worked at
the facility. The DSD could not say if Resident 2 received RNS on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025. The DSD stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could have a decline in mobility that could cause Resident 2 to be unable to use Resident 2's limbs and would make Resident 2 more dependent with care and activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself).
During an interview on 2/26/2025 at 11:06 am with Resident 2, Resident 2 stated the RNAs (unidentified) did not provide RNS to Resident 2 on 2/24/2025 or 2/25/2025. Resident 2 stated the RNAs (unidentified) say
they are providing RNS, but they either don't do it or only complete the order partially.
During a concurrent observation and interview on 2/26/2025 at 2:49 pm with RNA 5, Resident 2's RNS was observed. RNA 5 was observed providing BLE AAROM to Resident 2. RNA 5 was observed doing one set of 10 repetitions. RNA 5 stated RNA 5 was providing Resident 2 with leg extensions (to straighten the knee and hip from a bent or flexed position), leg flexion (to bend the knee and hip from a straight or extended position), lateral (side to side) movement, ankle rotation, flexion and extension.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055367 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 During a concurrent interview and record review on 2/26/2025 at 3:14 with RNA 5, Resident 2's RNFS dated 2/2025 was reviewed. RNA 5 stated Resident 2 was supposed to get three sets of 20 repetitions. RNA 5 Level of Harm - Minimal harm or stated RNA only provided one set of 10 repetitions to Resident 2. RNA 5 stated RNA 5 did not provide RNS potential for actual harm to Resident 2 on 2/25/2025. RNA 5 stated RNA 5 initialed Resident 2's RNFS on 2/25/2025 indicating the treatment was completed even though RNA 5 did not complete the treatment because RNA 5, was supposed Residents Affected - Some to. RNA 5 stated there were other dates in 2/2025 (unable to recall exact dates) where RNA 5 either did not give the complete treatment to Resident 2 or did not do Resident 2's RNS at all because RNA 5 did not have time. RNA 5 stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could become contracted, be in pain, and have a loss of function. RNA 5 stated RNA 5 should not have documented that RNA 5 completed Resident 2's RNS on 2/25/2025 or the other dates in 2/2025 (unable to recall exact dates) so other staff could know Resident 2 did not receive RNS. RNA 5 stated documenting Resident 2's RNS was complete when it was not meant that Resident 2 was not getting the care and services ordered by Resident 2's physician and cannot make up for the loss in treatment.
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, 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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055367
F-Tag F842
F-F842
Findings:
During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/4/2023, with diagnoses that included conversion disorder with mixed symptom presentation (mental health condition characterized by physical symptoms that cannot be explained by a medical or neurological condition), dysarthria (speech disorder characterized by difficulty in articulating words and producing clear speech due to weakness or poor coordination of the muscles involved in speech production), anarthria (characterized by the complete inability to articulate speech. caused by damage to the brain or nerves that control the muscles involved in speech production, such as the lips, tongue, and vocal cords), and unspecified neuropathy (a condition that involves damage to the peripheral nervous system from injury or disease process).
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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 055367 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 During a review of Resident 2's (CP) titled Care Plan Report, initiated on 10/20/2024, the CP indicated Resident 2 was at risk for decreased muscle strength. The CP goals indicated to maintain/increase muscle Level of Harm - Minimal harm or strength. The CP interventions included RNA for BLE AAROM exercises daily, 5 days per week of 20 potential for actual harm repetitions, 3 sets of each exercise or as tolerated by patient.
Residents Affected - Some During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 1/9/2025, the MDS indicated Resident 2 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 2 was dependent (helper does ALL the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfers. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self, personal hygiene, and rolling left and right.
During a review of Resident 2's RNFS for 1/2025 and 2/2025, the RNFS indicated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed the Resident 2's RNFS to indicate RNA 2 provided AAROM exercises to Resident 2 as ordered by Resident 2's physician. The RNFS indicated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2's RNFS to indicate RNA 1 provided AAROM exercises to Resident 2. The RNFS indicated on 2/3/2025, 2/5/2025 to 2/7/2025, 2/10/2025, 2/12/2025 to 2/14/2025, 2/18/2025 to 2/21/2025, 2/24/2025, and 2/25/2025, RNA 5 initialed Resident 2's RNFS to indicate RNA 5 provided AAROM exercises to Resident 2 as ordered by the physician.
During a concurrent interview and record review on 2/26/2025 at 1:44 pm with the Director of Staffing Developing (DSD), RNA 1 and RNA 2's timecards and staffing sign-in sheets and Resident 2's RNFS for 1/2025 and 2/2025 were reviewed. The DSD stated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed Resident 2's RNFS indicating RNA 2 provided the RNS, however RNA 2 was not working (on 1/16/2025, 1/30/2025, and 1/31/2025). The DSD stated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2's RNFS indicating RNA 2 provided the RNS, however RNA 1 was not working (on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025). The DSD stated RNA 1 and RNA 2 no longer worked at
the facility. The DSD could not say if Resident 2 received RNS on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025. The DSD stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could have a decline in mobility that could cause Resident 2 to be unable to use Resident 2's limbs and would make Resident 2 more dependent with care and activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself).
During an interview on 2/26/2025 at 11:06 am with Resident 2, Resident 2 stated the RNAs (unidentified) did not provide RNS to Resident 2 on 2/24/2025 or 2/25/2025. Resident 2 stated the RNAs (unidentified) say
they are providing RNS, but they either don't do it or only complete the order partially.
During a concurrent observation and interview on 2/26/2025 at 2:49 pm with RNA 5, Resident 2's RNS was observed. RNA 5 was observed providing BLE AAROM to Resident 2. RNA 5 was observed doing one set of 10 repetitions. RNA 5 stated RNA 5 was providing Resident 2 with leg extensions (to straighten the knee and hip from a bent or flexed position), leg flexion (to bend the knee and hip from a straight or extended position), lateral (side to side) movement, ankle rotation, flexion and extension.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 055367 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 During a concurrent interview and record review on 2/26/2025 at 3:14 with RNA 5, Resident 2's RNFS dated 2/2025 was reviewed. RNA 5 stated Resident 2 was supposed to get three sets of 20 repetitions. RNA 5 Level of Harm - Minimal harm or stated RNA only provided one set of 10 repetitions to Resident 2. RNA 5 stated RNA 5 did not provide RNS potential for actual harm to Resident 2 on 2/25/2025. RNA 5 stated RNA 5 initialed Resident 2's RNFS on 2/25/2025 indicating the treatment was completed even though RNA 5 did not complete the treatment because RNA 5, was supposed Residents Affected - Some to. RNA 5 stated there were other dates in 2/2025 (unable to recall exact dates) where RNA 5 either did not give the complete treatment to Resident 2 or did not do Resident 2's RNS at all because RNA 5 did not have time. RNA 5 stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could become contracted, be in pain, and have a loss of function. RNA 5 stated RNA 5 should not have documented that RNA 5 completed Resident 2's RNS on 2/25/2025 or the other dates in 2/2025 (unable to recall exact dates) so other staff could know Resident 2 did not receive RNS. RNA 5 stated documenting Resident 2's RNS was complete when it was not meant that Resident 2 was not getting the care and services ordered by Resident 2's physician and cannot make up for the loss in treatment.
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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055367 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 46687
Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure accurate documentation of restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) provided to one of three sampled residents (Resident 2), according to the facility's policy and procedure (P&P) titled, Charting and Documentation, by failing to:
1. Ensure RNA 5 did not initial Resident 2's Restorative Nursing Flow Sheet (RNFS) when RNA 5 did not provide Resident 2 with range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) as ordered by the physician on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025.
2. Ensure RNA 1 and RNA 2 did not initial Resident 2's RNFS to indicate RNS was provided to Resident 2
on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025 when RNA 1 and RNA 2 were not clocked in to work on those dates.
These failures resulted in Resident 2's medical records to contain inaccurate information that could affect Resident 2's care and result in ROM decline.
Cross Reference