The inspection identified failures in how the facility monitored, documented, and reported signs of infection and complications to physicians.
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The resident, identified in inspection records only as Resident O, carries diagnoses of osteomyelitis, a serious bone infection, and schizophrenia.
A witness, another resident, walked to the social services office the following morning and reported what he had seen.
An inspector noticed the outdated posting at 9:40 that morning.
Federal inspectors visited the Pasadena facility on August 19, 2025, and documented the finding as part of a complaint investigation.
The resident, identified in inspection records only as Resident E, had a physician's order written at 1:16 p.m.
That was August 19, 2025, the day surveyors arrived for a complaint inspection.
When he asked a therapist why, he was told they didn't have enough staff.
Resident #2 was in his wheelchair with the brakes locked.
The resident had severe osteoporosis.
That is what federal inspectors found when they investigated a complaint at Monrovia Post Acute, a skilled nursing facility at 1220 E.
The temperature gauge read 50 degrees.