Health inspection·September 17, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the dignity of one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 left Resident 1 in soiled diapers following an episode of stool incontinence (lack of voluntary control over urination or defecation). This failure resulted in Resident 1 feeling frustrated and helpless and had the potential for Resident 1 to experience a decline in health and wellbeing.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including conversion disorder (a mental health condition characterized by unexplained neurological symptoms that are not caused by a physical medical condition) with mixed symptoms presentation, aphonia (loss of ability to speak), and general anxiety disorder (mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 1's care plan titled, Resident is incontinent with both bowel and bladder., initiated 10/5/2023, the care plan indicated CNA's (in general) needed to check Resident 1 for episodes of incontinence at least every two hours and change diaper as needed. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (the ability to think and make daily decisions) and was dependent (helper does all the effort) on staff for dressing and toileting hygiene. During an interview on 9/16/2025 at 12:23 PM, CNA 1 stated CNA 1 was assigned to care for Resident 1 on 9/16/2025 since 7 AM. CNA 1 stated Resident 1 was currently upset with CNA 1 and wanted a different CNA instead of CNA 1 to be assigned to care for Resident 1. CNA 1 stated CNA 1 did not know why Resident 1 was upset with CNA 1. During an observation on 9/16/2025 at 1:30 PM, Resident 1 was in bed. There was a foul odor of stool in the room. During a concurrent interview, Resident 1 communicated by typing on an iPad. Resident 1 had soiled herself earlier in the morning and requested to be changed by CNA 1 since 8 AM. Resident 1 indicated CNA 1 did not change Resident 1's soiled diaper and Resident 1 felt frustrated and helpless when CNA 1 left Resident 1 in a soiled diaper. During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (condition in which the heart cannot pump enough blood to all parts of the body). During a review of Resident 2's History and Physical (H&P) dated 9/12/2025, the H&P indicated Resident 2 could make her own decisions. During an interview on 9/16/2025 at 1:35 PM, Resident 2 (Resident 1's roommate) stated Resident 2 smelled stool in the room starting around 10 AM. During an interview on 9/16/2025 at 2:01 PM, CNA 2 stated CNA 2 replaced CNA 1 to provide care to Resident 1 at 12:30 PM on 9/16/2025. CNA 2 stated Resident 1 was soiled when the CNA entered Resident 1's room at 12:30 PM. CNA 2 stated the CNA assigned to Resident 1 should check Resident 1 every two hours to check if the resident needed to be changed after incontinent episodes. During a follow up interview on 9/16/2025 at 2:06 PM, CNA 1 stated CNA 1 had not changed Resident 1 Page 1 of 2 055367 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 from 7 AM until 12:30 PM when CNA 1 was reassigned to other residents (in general). CNA 1 stated CNA 1 did not check Resident 1 at least every two hours to see if Resident 1 had soiled herself. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, dated February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, Individual needs and preferences of the resident are identified through the assessment process. 055367 Page 2 of 2