Monrovia Gardens Healthcare Center
615 W. Duarte Rd. · Monrovia, CA · 91016 · 6263584547
96 certified beds For profit - Limited Liability company Chain: Cambridge Healthcare Services
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
61% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.15 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.41 | 0.55–0.75 |
| Weekend hours / resident-day | 3.78 | ≈ weekday level |
| Nursing turnover / year | 61% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (99 in the current record)
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Potential for harm · E March 3, 2026 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 23, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 3, 2026 · found via complaint
Provide appropriate foot care.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · D March 3, 2026 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · D December 19, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 30, 2025 · Resident Rights
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Potential for harm · E December 19, 2025
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.
Corrected December 29, 2025 · Resident Rights
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Potential for harm · D December 19, 2025
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected December 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected December 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2025
Provide activities to meet all resident's needs.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · E December 19, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2025
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.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · E December 19, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 29, 2025 · Pharmacy Service
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Potential for harm · E December 19, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 29, 2025 · Nutrition and Dietary
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Potential for harm · D December 19, 2025
Provide and implement an infection prevention and control program.
Corrected December 29, 2025 · Infection Control
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Potential for harm · D December 19, 2025
Implement a program that monitors antibiotic use.
Corrected December 29, 2025 · Infection Control
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Potential for harm · D October 31, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 17, 2025 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected November 23, 2025 · Resident Rights
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Potential for harm · D September 3, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected September 23, 2025 · Resident Rights
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Potential for harm · E September 3, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 24, 2025 · Quality of Life and Care
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Potential for harm · D September 3, 2025 · found via complaint
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.
Corrected September 23, 2025 · Nutrition and Dietary
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Potential for harm · E August 27, 2025 · found via complaint
Keep all essential equipment working safely.
Corrected September 15, 2025 · Environmental
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Potential for harm · E August 5, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected August 27, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055367 · certified since December 31, 1971. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.