Monroe Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow current infection control standards for six residents (Residents #87, #4, #75, #1, #53, and #18), in a review of 20 sampled residents, when staff failed to follow enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multi drug resistant organism (MDRO) or any resident who has a chronic wound and/or indwelling medical device) to prevent infection while providing personal care, failed to ensure urinary catheter (a flexible tube inserted into the bladder) tubing was not on the floor, failed to ensure oxygen tubing was properly stored when not in use, and failed to follow the facility's policy and procedure for handwashing, gloving, handling of linens and respiratory therapy. The facility census was 82. Review of the facility's undated policy, Handwashing/Hand Hygiene, showed the following:-This facility considers hand hygiene the primary means to prevent the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to follow professional standards and the facility's policy/procedure for failing to complete a dressing change per proper technique for one resident (Resident #53) who had surgical wound and history of infection in the surgical wound which had recently been treated with antibiotics, in a review of 20 sampled residents. The facility census was 82. Review of the facility's undated clean dressing change checkoff showed the following:-Verify and review physician's orders;-Remove dirty dressing and place in trash can;-Clean wound with gauze and cleaning solution using a single outward strokes and separate gauze for each cleansing wipe;-Use dry gauze to pat the wound;-Apply clean dressing as ordered. Review of the National Library of Medicine, MedlinePlus.gov, last reviewed on 01/21/25, showed the following steps should be followed when changing a wet to dry dressing:-Pour saline into a clean bowl. Place gauze pads and any gauze packing tape you will use in the bowl;-Squeeze the saline from the gauze pads or packing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide two residents (Resident #9 and #4), who relied on staff to assist with their activities of daily living (ADLs), in a review of 20 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 82. Review of the facility policy, Perineal Care, dated March 2019, showed the following:-Purpose was to keep perineal clean and to prevent infection and odors in the perineal area;-Staff must clean all areas of the skin that are touched by soiled brief. Review of the facility policy, Indwelling Catheter Care, reviewed November 2025, showed when providing care to an uncircumcised male, retract the foreskin, cleanse the meatus as described, and return the foreskin to normal position. Review of Medline Plus Medical Encyclopedia, reviewed 07/01/25, showed the following:-Penis care (uncircumcised);-Gently retract the foreskin during bathing and clean the penis well. It is very important to reposition the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff monitored and provided hand hygiene for one resident (Resident #6), in a review of ten sampled residents. Resident #6 had diagnosis of dementia and was incontinent of bowel and bladder. The resident wandered and continually placed his/her hands in his/her pants and fondled his/her genitalia. Resident #6 touched multiple items on the unit including a resident's meal tray, food items, drinking glasses, and a water pitcher on a medication cart without appropriate hand hygiene. The facility census was 80. Review of the undated facility policy, Hand Hygiene, showed the following: -When to use soap and water: -When hands are visibly dirty or visibly soiled with blood or other body fluids; -Before eating and after using the restroom; -After approximately 10 uses of Alcohol-based hand gel or hands feel tacky from use hand gel; -When to use alcohol-based hand gel: -Before and after resident contact; -After body fluid exposure or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three residents (Residents #2, #1, and #3), in a review of four sampled residents, received care and/or services per physician's orders and professional standards of care. Staff failed to ensure Resident #2, who had a significant wound/skin history, had weekly skin assessments completed and/or documented as ordered, and failed to obtain a follow up urinalysis (urine test used to detect an infection) ordered on 08/01/24. The facility failed to obtain labs as ordered and failed to follow up timely on lab results to monitor Resident #1's potassium level, who had a diagnoses of hypokalemia (low blood potassium level) and an ileus (a temporary condition where your intestine can't push food and waste out of your body which can be caused by chemical, electrolyte, or mineral imbalances such as decreased blood potassium level). The facility failed to follow discharge orders for Resident #3 by failing to complete dressing changes as ordered.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when two residents (Residents #1 and #2), in a review of four sampled residents, had a change in condition. The facility's census was 68. 1. Review of an email received from the facility's Director of Nursing (DON) on 11/13/24 showed the facility did not have a policy for when to notify physician. 2. Review of the Resident #1's face sheet showed the following: -He/She admitted to the facility on [DATE]; -Diagnoses included an ileus. Review of the resident's Nursing Progress Note, dated 08/01/24 at 7:04 A.M., showed the resident's physician examined the resident and reviewed medications with no new orders. Review of the resident's Physician's Progress Note, dated 08/01/24, showed the following: -The resident was admitted for rehabilitation on 07/26/24; -The resident had a history of dementia and congestive heart failure (the heart cannot pump blood well enough to give the body a normal supply) with recent hospitalization; -The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a physician's order was obtained to continue an indwelling urinary catheter for one resident of two residents (Resident (R) 19) reviewed for catheters. Findings include: Review of R19's undated Face Sheet from the Face Sheet section of the Resident tab of the electronic medical record (EMR) revealed R19's relevant diagnoses included urinary tract infection; chronic kidney disease, stage 3, and retention of urine. Review of the Census section of the Resident tab in the EMR revealed R19 was initially admitted to the facility on [DATE]. R19 most recently discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of R19's Progress Notes section of the Resident tab in the EMR revealed on 03/01/24 at 2:24 AM, R19 returned from the emergency room with an indwelling foley catheter placed and instructions to retain catheter until treating physician decides on removal.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to ensure the Attending Physician for one of five residents (Resident (R) 41) reviewed for unnecessary medications provided a rationale for not following the Consultant Pharmacist's recommendation related to an anti-anxiety medication that was ordered as needed (PRN) without a stop date. This had the potential for the resident being administered medication unnecessarily. Findings include: Review of the undated facility policy titled Drug Regimen Review Policy stated .5. Each resident's primary care physician must respond to consult reports within 10 business days. If this is not followed, the medical director will be consulted for further intervention.7. If PCP (primary care provider) does not wish to make change as recommended on a pharmacist consult report, they will be required to document their rationale as to why, on the report. Review of R41's medications located in the electronic medical record (EMR) under the Resident Documents tab revealed an order dated 02/06/24 for lorazepam 0.5 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a comprehensive care plan for four residents (Residents #6, #13, #42 and #173). The facility did not address or include interventions for the following: Resident #6 was a smoker, resident #13 utilized oxygen therapy, resident #42's pain or resident #172's pressure ulcers and presence of a wound vac. The facility census was 70. 1. During interview on 4/28/22 at 2:08 P.M., the Director of Nurses (DON) said the facility did not have a policy for updating care plans. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for four residents (Resident #25, #36, #43 and #67), in a review of 21 sampled residents. The facility census was 70. During interview on 4/28/22 at 2:08 P.M., the Director of Nurses (DON) said the facility did not have a policy for updating care plans. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for four residents (Resident #6, #36, #57, and #67), of 21 sampled residents, who had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine). The facility reported twelve residents with indwelling catheters. The facility census was 70. 1. Review of the facility policy Indwelling Catheter Care dated 11/19 showed the intent of the facility policy was to ensure that the residents receive care and services to prevent urinary tract infections in those residents with indwelling catheters, in accordance with standards of practice. Procedure: 1. Perform hand hygiene before beginning the procedure and assemble all supplies; 2. Knock before entering the room, introduce self, and explain procedure to the resident; 3. Place supplies on the bedside table or over bed table and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to adequately provide ordered treatments, and failed to prevent further tissue damage for one resident (Resident #6) who had one Stage II pressure ulcer, (A partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) and one Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer which were not present upon admission. Facility staff failed to complete ordered treatments timely and did not properly reposition the resident while in the bed. The facility census was 70. Review of the facility policy Clean Dressing Change, dated November 2019 showed the intent was to ensure dressings are changed in accordance with the State and Federal guidelines. #19. Apply clean…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to administer medications with an error rate of less than 5% when staff failed to administer medications separately via peg tube (tube inserted through the abdominal wall into the stomach to provide medications and nutrition) for one resident (Resident #7), in a review of 21 sampled residents. There were 31 opportunities with three errors, which resulted in an error rate of 9.68 %. The facility census was 70. Review of the facility's policy, Enteral Feeding Medication Administration, dated 11/2019, showed the following: -It is the policy of the facility to provide appropriate medication administration to residents who receive their medications via an enteral feeding tube to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance to State and Federal regulation; -Prior to medication administration, flush the tube with 30 milliliters (ml) of water, mix each crushed medication with five to ten ml of water and flush with ten ml of water between each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.