Monrovia Gardens Healthcare Center

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nervous system from injury or disease process). During a concurrent observation and interview on 8/29/2025 at 4:38 pm, inside Resident 4's room, Resident 4's call light was observed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 4 was unable to reach the call light. During a concurrent

observation and interview on 8/29/2025 at 5:14 pm, inside Resident 4's room, Resident 4's call light was observed with Certified Nurse Assistant (CNA) 1. CNA 1 stated, I let them (Resident 4) I come in because

the call light is not working and not within reach. During a concurrent observation and interview on 8/29/2025 at 5:23 pm, inside Resident 4's room, Resident 4's call light was observed with LVN 1. LVN 1 stated, This is the first time I have seen the cord pulled out from the wall. During an interview on 9/3/2025 at 1:49 pm, with the Director of Nursing (DON), the DON stated [maintenance staff] had the call light cord secured to the wall in Resident 4's room, but 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

physical symptoms that cannot be explained by a medical or neurological causes) with mixed symptoms presentation, aphonia (inability to produce voiced sound), and generalized anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of untitled Care Plan (CP), initiated on 10/14/2023 and revised on 7/31/2025, the CP indicated Resident 4 was incontinent (inability to control the bladder and bowels) with both bowel and bladder in relation to impaired mobility and inability to alert staff of Resident 4's urges. The CP indicated Resident 4 was at risk for infection, skin breakdown, and was on a check and change program. The CP goals indicated Resident 4 would be kept clean, dry, and odor free daily for three months. The CP interventions indicated that CNAs were to check Resident 4 for bladder incontinence at least every two hours, as needed, and to increase frequency as needed, keep Resident 4's call light within reach and answer promptly, to monitor as indicated for redness or skin breakdown, and to report to MD (medical doctor, physician). During a review of Resident 4's MDS, dated [DATE REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the right diet and texture prescribed by the physician. The DON stated if resident trays were not checked appropriately then residents could get served the wrong food and or diet. The DON stated a resident with a minced and moist diet should be given bread that's minced and moist otherwise they could aspirate (the accidental breathing in of food or fluid into the lungs, potentially causing pneumonia [inflammation and fluid

in lungs] or other lung problems). The DON stated if a resident aspirated, they could choke, and that was dangerous. During a review of the facility's P&P titled, Therapeutic Diets, revised 12/2008, the P&P indicated the Food Services Manager would establish a tray identification system to ensure that each resident received his or her diet as ordered. During a review of the facility's P&P titled, Tray Identification, undated, the P&P indicated the appropriate identification 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.

Event ID:

Facility ID:

If continuation sheet