Monrovia Gardens Healthcare Center

In the surveyor’s words

From the most serious findings on record at Monrovia Gardens Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 24, 2025

  Based on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 12) as indicated in the facility's policies and procedures (P&P) titled, Falls and Fall Risk, Managing, Safety and Supervision of Residents, and Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4 and/or Licensed Vocational Nurse (LVN) 6 provided supervision/monitoring (the act of watching a person) to Resident 12, who was assessed as being high risk for falls and had a history of multiple falls when CNA 4 and LVN 6 failed to prevent Resident 1 from being inside the facility's conference room with… […]

• No harm, potential for more than minimal, patternF757Jun 23, 2026

  Based on interview and record review, the facility failed to monitor for side effects (unpleasant or adverse reactions) for two of three sampled residents (Residents 1 and 3) who were prescribed opioid medications (a class of drugs that act on the nervous system to relieve pain) while at the facility.These failures resulted in necessary medication and had the potential for Residents 1 and 3 to experience side effects from opioid medications while in the care of the facility. (Cross Reference F552)a. […]

• No harm, potential for more than minimal, patternF657Mar 3, 2026

  Based on interview and record review, the facility failed to revise the care plan interventions for one of four sampled residents (Resident 1) who had a weight loss of 24 pounds (lbs.) in one month.This deficient practice placed Resident 1 at risk for continued weight loss and had the potential for Resident 1 to receive inappropriate care and treatment.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant… […]

• No harm, potential for more than minimal, patternF578Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 10, Resident 1, and Resident 51), had information regarding Advance Directives (AD - legal document indicating resident preference on end-of-life treatment decisions) filed in Resident 10, Resident 1, and Resident 51's medical records as indicated in the facility's policy and procedure (P&P) titled, Advance Directives.This deficient practice had the potential to cause confusion among the healthcare providers in the event Resident 10, Resident 1 and Resident 51 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment/services regarding life-sustaining treatment. […]

• No harm, potential for more than minimal, patternF684Dec 19, 2025

  Based on interview and record review the facility failed to ensure necessary care and services were provided for two of two sampled residents (Residents 48 and 51) by failing to:a. Ensure Resident 48's neurology (the branch of medicine that deals with the brain, spinal cord, and nerves) consult (getting expert opinion or advice about a patient's condition) was ordered in a timely manner.b. Ensure Resident 51 did not self-administer Pepto Bismol Ultra (a double-strength medication used to relieve nausea, heartburn, indigestion, upset stomach and diarrhea) brought from home and kept at Resident 51's bedside without a physician's order. This deficient practice resulted in the delay of care for Resident 48 and had the potential to result in unmet physical needs to Resident 48. […]