Monrovia Gardens Healthcare Center
MONROVIA GARDENS HEALTHCARE CENTER in MONROVIA, CA — inspection on September 3, 2025.
Found 3 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
from the wall.
During an interview on 9/3/2025 at 1:49 pm, with the Director of Nursing (DON), the
realized it was still not secured so another piece was bought but had not been installed yet.
The DON stated it was noticed the prior week (before the day of interview) that Resident 4's call light was still not secured to the wall, but did not remember the exact date.
The DON stated [facility staff] needed to make sure the call light was connected to the wall and within reach to ensure it was working and Resident 4 could ask for help.
During a review of the facility's undated policy and procedure (P&P) titled, Answering the Call Light, the P&P indicated the purpose of the procedure was to ensure timely responses to the resident's requests and needs.
The P&P indicated to be sure the call light was plugged in and functioning at all times, and to ensure the call light was accessible to the resident when in bed, from the toilet, from the shower, or bathing facility, and from the floor.
055367 09/03/2025
Monrovia Gardens Healthcare Center 615 W.
Duarte Rd.
Monrovia, CA 91016
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had intact cognition (ability to think, remember, and function).
The MDS indicated Resident 4 had the absence of spoken words.
The MDS indicated Resident 4 had seven to 11 days (half or more of the days) feeling down, depressed (common and serious illness that negatively affects how one feels, thinks and acts) or hopeless.
The MDS indicated Resident 4 was dependent (helper does ALL the effort to complete the activity) with toileting hygiene and chair/bed-to-chair transfers.
The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort to complete activity) with personal hygiene, showering/bathing self, and rolling left and right (in bed).
The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to lying, lying to sitting on side of bed, and sitting to standing.
The MDS indicated Resident 4 had hereditary (passed down from parent to child) and idiopathic (no identifiable cause) neuropathy (a condition that involves damage to the peripheral nervous system from injury or disease process).
During an observation on 8/29/2025 at 4:30 pm, inside Resident 4's room, Resident 4 was observed with Certified Nurse Assistant (CNA 1).
CNA 1 moved Resident 4 to Resident 4's right side. Resident 4's brief was observed to have yellowish color on the lower side of the brief, and brown-colored stool (feces) that was medium in size.
During a concurrent observation and interview on 8/29/2025 at 5:14 pm, inside Resident 4's room, Resident 4 was observed with CNA 1. CNA 1 stated Resident 4's wet brief was yellow in color. CNA 1 stated Resident 4's bed sheet smelled of urine. Resident 4 typed on Resident 4's tablet, I was not changed since yesterday (8/28/2025) at 2 pm.
During an interview on 8/29/2025 at 5:25 pm with CNA 1, CNA 1 stated the left side of Resident 4's bed sheet and gown were wet. CNA 1 stated Resident 4's whole brief was wet.
During an interview on 9/3/2025 at 1:39 pm, with the Director of Nursing (DON), the DON stated hair brushing was part of activities of daily living (ADL, the tasks of everyday life fundamental to caring for oneself) and should be done after a shower, as part of morning care, and as needed.
The DON stated morning care included oral care, washing of face, peri care, and hair brushing.
The DON stated if hair is not brushed it could matte, tangled and if bad enough, could need to be cut.
The DON stated matted hair could cause discomfort.
The DON stated having matted hair could make a resident feel like there are not cared for.
The DON stated (in general) residents' briefs should be checked and changed every two hours and as needed.
The DON stated this was to ensure residents' briefs were, Not soaked, and were not uncomfortable.
The DON stated being left wet or having matted hair could lead to psychosocial issues.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
055367 09/03/2025
Monrovia Gardens Healthcare Center 615 W.
Duarte Rd.
Monrovia, CA 91016
During a review of the
coding shall be used to identify various diets.
The P&P indicated the Food Services Manager, or supervisor would check the trays for correct diets before the food carts were transported to their designated areas.
The P&P indicated nursing staff shall check each food tray for the correct diet before serving the resident.
The P&P indicated if there was an error, the nurse supervisor would notify the dietary department immediately by phone so that the appropriate food tray can be served.
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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.