Monrovia Post Acute

In the surveyor’s words

From the most serious findings on record at Monrovia Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure a Hoyer lift sling (a supportive fabric device that cradles an individual used with a Hoyer lift [a patient lift, a mechanical device with lifting mechanism] to safely transfer individuals with limited mobility between a bed, wheelchair, or toilet) was maintained in a safe and functional condition prior to a transfer for one of two sampled residents (Resident 2). As a result, on 6/4/2026, the Hoyer lift sling ripped while Resident 2 was lifted off the bed, suspending Resident 2 in the air. Resident 2 fell from the Hoyer lift to the floor. […]

• Actual harm, isolatedF689Jul 22, 2024

  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 1) as indicated in the facility's policies and procedures (P&P) titled, Safety and Supervision of Residents, and Falls and Fall Risk, Managing, by failing to: 1. Ensure Certified Nursing Assistant 1 and/or Licensed Vocational Nurse 1 provided supervision/monitoring when Resident 1, who was assessed as being high risk for falls, had increased agitation and confusion, repeated episodes of getting out of bed, and ambulating in Resident 1's room unassisted. 2. […]

• No harm, potential for more than minimal, patternF880Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices for four of eight sampled residents (Residents 1, 5, 6, and 7) by failing to:Ensure Resident 1's bedside dresser was clean.Ensure Residents 1, 5, 6, and 7's shared bathroom closet area was clean.These failures had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to Residents 1, 5, 6, and 7.A&B. […]

• No harm, potential for more than minimal, patternF584Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment when:a. There was black substance on the caulk (a flexible sealing material used to fill gaps, cracks, and joints to prevent air, water, dust, and contaminants from passing through) in two of two showers (Shower 1 and Shower 2) located inside one of two facility shower rooms.b. The cove base (a type of vinyl and or rubber trim that's applied to the edges of a floor to help create a smooth transition between the floor and the wall) in the shared bathrooms of three of three sampled resident rooms (Rooms 1, 31 and 35) and the wall close to the bathroom door inside room [ROOM NUMBER] was loose and had a gap from the wall. […]

• No harm, potential for more than minimal, patternF684Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 3 and 14) received nursing care and services in accordance with professional standards of practice.For Resident 3 the facility failed to ensure the physician notification was completed and act upon a change in condition (CIC) when Resident 3 experienced the following: On 4/2/2026 Resident 3's sodium level (Normal sodium levels = 135 to 145 milliequivalent per liter (meq/L)) was 131 meq/L (low).Resident 3's level of consciousness was altered and Resident 3 was lethargic (consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep). […]