Inspection citations
18’23
27’24
49’25
10’26
104 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 15, 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 |
| Jul 8, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Jul 8, 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. | Complaint |
| Jul 8, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Jun 23, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Jun 23, 2026 | E · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Complaint |
| Jun 4, 2026 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Complaint |
| Mar 3, 2026 | E · 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 |
| Mar 3, 2026 | D · potential | Provide appropriate foot care. | Complaint |
| Mar 3, 2026 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Dec 19, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Dec 19, 2025 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Dec 19, 2025 | D · potential | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Routine |
| Dec 19, 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 |
| Dec 19, 2025 | 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. | Routine |
| Dec 19, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Dec 19, 2025 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 19, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Dec 19, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Dec 19, 2025 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Dec 19, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Dec 19, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 19, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 19, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 19, 2025 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Oct 31, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Sep 17, 2025 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Sep 3, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Sep 3, 2025 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Sep 3, 2025 | D · potential | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Complaint |
| Aug 27, 2025 | E · potential | Keep all essential equipment working safely. | Complaint |
| Aug 5, 2025 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Aug 5, 2025 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Aug 5, 2025 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Complaint |
| Jul 9, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Jul 9, 2025 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Complaint |
| Jul 9, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 13, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| May 13, 2025 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| May 13, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Apr 24, 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 |
| Apr 24, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Mar 27, 2025 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| Mar 27, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Mar 27, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Mar 27, 2025 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Mar 27, 2025 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Complaint |
| Mar 27, 2025 | D · potential | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Complaint |
| Feb 26, 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. | Complaint |
| Feb 26, 2025 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| Feb 26, 2025 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Feb 10, 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 |
| Jan 24, 2025 | D · potential | Ensure residents have reasonable access to and privacy in their use of communication methods. | Complaint |
| Jan 24, 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 |
| Jan 24, 2025 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Jan 24, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 24, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 24, 2025 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Jan 24, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Dec 31, 2024 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Dec 24, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Dec 24, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Nov 25, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Oct 31, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Oct 31, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Oct 31, 2024 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Oct 31, 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 |
| Oct 31, 2024 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Routine |
| Oct 31, 2024 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Oct 31, 2024 | 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 |
| Oct 31, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Oct 31, 2024 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Oct 31, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Oct 31, 2024 | E · 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 |
| Oct 31, 2024 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Oct 31, 2024 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Oct 31, 2024 | D · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| Oct 31, 2024 | 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 |
| Oct 31, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 31, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 31, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Jun 21, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 29, 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. | Complaint |
| May 9, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| May 9, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 9, 2024 | E · potential | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Complaint |
| Oct 19, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Oct 19, 2023 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Oct 19, 2023 | 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 |
| Oct 19, 2023 | 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. | Routine |
| Oct 19, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Oct 19, 2023 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Oct 19, 2023 | 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 |
| Oct 19, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Oct 19, 2023 | 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. | Routine |
| Oct 19, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Oct 19, 2023 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Oct 19, 2023 | D · potential | Provide timely, quality laboratory services/tests to meet the needs of residents. | Routine |
| Oct 19, 2023 | D · potential | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Routine |
| Oct 19, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 19, 2023 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Routine |
| Oct 19, 2023 | D · potential | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Routine |
| Oct 19, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 11, 2023 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
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 Gardens Healthcare Center
615 W. Duarte Rd., Monrovia, CA 91016 · (626) 358-4547
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055367
- Certified beds
- 96
- Legal owner
- Ag Monrovia, LLC
- Part of
- Cambridge Healthcare Services
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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