Inspection citations
14’24
28’25
18’26
60 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 4, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Aug 4, 2026 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Complaint |
| Jul 16, 2026 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 10, 2026 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 24, 2026 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Apr 24, 2026 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Routine |
| Apr 24, 2026 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Apr 24, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 24, 2026 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Apr 24, 2026 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Apr 24, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Apr 24, 2026 | D · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| Apr 24, 2026 | D · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Apr 24, 2026 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 12, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 6, 2026 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| Feb 6, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jan 6, 2026 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| Oct 27, 2025 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Oct 27, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Aug 20, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 20, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Aug 20, 2025 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Complaint |
| Aug 20, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Aug 20, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Aug 20, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Aug 20, 2025 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Complaint |
| Aug 20, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jun 10, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| May 15, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| May 15, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 15, 2025 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Complaint |
| May 15, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Complaint |
| Mar 20, 2025 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Mar 20, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Mar 6, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Mar 6, 2025 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Mar 6, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Mar 6, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Mar 6, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 21, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 21, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Feb 21, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 21, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Feb 21, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Feb 21, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jul 22, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jul 22, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 5, 2024 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Complaint |
| Apr 5, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Feb 8, 2024 | D · potential | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Routine |
| Feb 8, 2024 | E · potential | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Routine |
| Feb 8, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Feb 8, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Feb 8, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Feb 8, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Feb 8, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Feb 8, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 8, 2024 | E · potential | Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Routine |
| Feb 8, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Monrovia Post Acute
1220 E. Huntington Drive, Duarte, CA 91010 · (626) 359-6618
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055259
- Certified beds
- 82
- Legal owner
- Monrovia Post Acute LLC
- Part of
- Serrano Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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