The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited January 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
MONROVIA GARDENS HEALTHCARE CENTER
MONROVIA, CA · Medicare-certified · 96 beds
Needs attention
For-profitChain member
1 of 5 overall
MONROVIA GARDENS HEALTHCARE CENTER in Monrovia, CA has a 1 of 5 overall rating, with a 1-star health inspection rating, 2-star staffing, and 3-star quality measures. It is flagged with the lowest overall rating; reported nurse staffing is 4.15 hours per resident per day, slightly above the federal benchmark of 4.1, and there were $0 in fines in the last 24 months.
Facility ratings
Health inspections
Staffing
4.1494 hrs/resident/day
Quality measures
Last inspection: March 3, 2026Penalties, last 24 months: $0lowest overall rating
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.1494.
Staffing detail
- Registered nurses
- 0.41
- Licensed practical nurses
- 1.19
- Nurse aides
- 2.55
- Weekend nursing
- 3.78
Hours per resident per day.
Total staff turnover: 61%
Registered nurse turnover: 63%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
18.4%Improving
Residents with a fall causing major injury
1.5%Worsening
Residents with pressure ulcers (bedsores)
4.8%Worsening
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
5%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
9%Worsening
Residents whose ability to walk got worse
11.6%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
8.4%Improving
Short-stay residents newly given an antipsychotic
1%Worsening
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
6.2%Improving
Residents with depressive symptoms
24.2%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
97.3%Steady
Short-stay residents given the pneumonia vaccine
100%Steady
What the inspectors found
The home failed to complete and keep the resident’s care plan properly prepared, reviewed, and updated by the right health professionals. Cited March 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 657 — 42 CFR §483.21(b)(2) — S/S: E
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited December 2025 — limited pattern, potential for harm.
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F-Tag 684 — 42 CFR §483.25 — S/S: E
The home failed to honor residents’ choices about treatment, research participation, and advance care instructions. Cited December 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 578 — 42 CFR §483.10 — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited December 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 15 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of CAMBRIDGE HEALTHCARE SERVICES · 32 homes · 2.6 stars avg
- Occupancy
- 80.1 residents on an average day (83% of 96 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 54 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.