Public Record
Monrovia Gardens Healthcare Center
Operated by Cambridge Healthcare Services
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 96
- Avg. residents per day
- 80.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 102
- Fire safety findings
- 15
- Inspections on file
- 29
- Last inspection
- 2026-03-03
*CMS
*CMS
*CMS
*CMS
Citations
102 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0693Generalpotential for harm
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.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0606Generalpotential for harm
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
- 0578Generalpotential for harm
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.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0557Generalpotential for harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0808Generalpotential for harm
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.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0807Generalpotential for harm
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0688Generalpotential for harm
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.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0584Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0726Generalpotential for harm
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.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0576Generalpotential for harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0578Generalpotential for harm
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.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0625Generalpotential for harm
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.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0790Generalpotential for harm
Provide routine and 24-hour emergency dental care for each resident.
- 0803Generalpotential for harm
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.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0882Generalpotential for harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 0688Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0770Generalpotential for harm
Provide timely, quality laboratory services/tests to meet the needs of residents.
- 0773Generalpotential for harm
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0825Generalpotential for harm
Provide or get specialized rehabilitative services as required for a resident.
- 0837Generalpotential for harm
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.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0584Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection3 deficiencies
- View inspection reportInspectionFire Safety7 deficiencies
- Inspection15 deficiencies
055367 12/19/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or…
Read full statement of deficiencies - View inspection reportInspection1 deficiency
- Inspection1 deficiency
055367 09/17/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions…
Read full statement of deficiencies - Inspection3 deficiencies
055367 09/03/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility to…
Read full statement of deficiencies - Inspection1 deficiency
055367 08/27/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure swamp…
Read full statement of deficiencies - Inspection3 deficiencies
055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT…
Read full statement of deficiencies - Inspection3 deficiencies
055367 07/09/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility staff…
Read full statement of deficiencies - Inspection3 deficiencies
055367 05/13/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016 F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility…
Read full statement of deficiencies
Showing the 10 most recent inspections. 19 earlier inspections are also on record.
Ownership
Cambridge Healthcare Services
32nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Monrovia Gardens Healthcare Center?
- Monrovia Gardens Healthcare Center is a Medicare- and Medicaid-certified nursing home in Monrovia, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 055367.
- What is the CMS rating for Monrovia Gardens Healthcare Center?
- Monrovia Gardens Healthcare Center has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Monrovia Gardens Healthcare Center have?
- Monrovia Gardens Healthcare Center is certified for 96 beds. It serves an average of 80.1 residents per day.
- How many citations does Monrovia Gardens Healthcare Center have?
- Monrovia Gardens Healthcare Center has 102 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Monrovia Gardens Healthcare Center last inspected?
- Monrovia Gardens Healthcare Center was last inspected on March 3, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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