A list of the most recent deficiencies for Monrovia Gardens Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-19 | 2023-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-11-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-19 | 2023-11-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-19 | 2023-11-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-19 | 2023-11-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-19 | 2023-11-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-19 | 2023-11-14 | N |
| 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. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-10-19 | 2023-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-10-19 | 2023-11-14 | N |
| 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. | Health | 2023-10-19 | 2023-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-11-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-23 | 2023-11-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-23 | 2023-11-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-11 | 2023-10-25 | Y |
| 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. | Health | 2023-07-15 | 2023-08-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-06 | 2023-07-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-20 | 2023-05-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-20 | 2023-05-10 | Y |
| Keep all essential equipment working safely. | Health | 2023-04-20 | 2023-05-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-02-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-13 | 2023-01-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-13 | 2022-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-13 | 2022-12-16 | N |
| 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. | Health | 2022-11-13 | 2022-12-16 | N |
| 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. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-13 | 2022-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-13 | 2022-12-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-13 | 2022-12-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-13 | 2022-12-16 | N |
| 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. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-13 | 2022-12-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-13 | 2022-12-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-13 | 2022-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-13 | 2022-12-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-13 | 2022-12-16 | N |
| 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. | Health | 2022-11-13 | 2022-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-13 | 2022-12-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-13 | 2022-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-13 | 2022-12-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-13 | 2022-12-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-12 | 2022-12-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-10 | 2022-11-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-11-10 | 2022-11-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-31 | 2022-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-20 | 2022-06-02 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-28 | 2022-04-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-28 | 2022-04-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-04 | 2022-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-09 | 2022-02-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-11 | 2022-01-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-11 | 2022-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-11-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-10 | 2021-09-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-09-17 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-02 | 2021-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-30 | 2021-05-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-30 | 2021-05-18 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-30 | 2021-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-05-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-08 | 2019-12-05 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-11-08 | 2019-12-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-08 | 2019-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-05 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-08 | 2019-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-08 | 2019-12-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-08 | 2019-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-08 | 2019-12-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-08 | 2019-12-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-08 | 2019-12-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-08 | 2019-12-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-07 | 2019-12-03 | N |
