Monarch Meadows Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Monarch Meadows Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 8, 2021

  Based on observation, record review, and staff interviews, the facility failed to provide appropriate supervision to a resident while eating that was at high risk for choking. This resulted in actual harm when Resident #11 was left unsupervised alone, in the room to eat and the resident choked on food, requiring the [MEDICATION(S)] Maneuver to be performed. Subsequently the resident developed aspiration pneumonia requiring treatment. The facility failed to provide supervision again for the resident during a meal observation of the resident eating alone in the room. This affected one (#11) of the three residents sampled for assistance with Activities of Daily Living (ADL). […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2025

  Based on observations staff interviews, policy review, and record review, the facility failed to store and prepare foods and maintain the kitchen in a sanitary manner. This had the potential to affect 46 residents who received food from the kitchen. The facility census was 47. Findings include: Observation on 09/15/25 at 8:45 A.M. of the kitchen revealed the following concerns: In the handwashing area, the garbage container was filled with used towels and was not covered. In the walk-in refrigerator, there was an unsealed bowl of cottage cheese with no label and no date. There was a container of chopped ham with no label and dated 09/11/25 and a container of cottage cheese dated 09/11/25. There were five plates of salads with no label and no date. […]

• No harm, potential for more than minimal, widespreadF812Jul 8, 2021

  Based on observation, recipe review, policy reviews and staff interviews, the facility failed to appropriately store and prepare food items. This had the potential to affect 48 of 48 residents who resided in the facility and received their meals from the kitchen. Findings include: 1. Observation on 07/06/21 at 11:30 A.M., of Dietary Manager (DM) #135 pureeing the lunch meal revealed ham was placed in the robot coupe canister, water was added to the ham, and the ham and water were blended together. DM #135 then added more water to the mixture and blended them together. DM #135 added powdered thickener to the ham and water mixture and blended it again then poured the mixture into a pan on the steam table. […]

• No harm, potential for more than minimal, isolatedF578Sep 18, 2025

  Based on record review and staff interviews, the facility failed to ensure signed Do Not Resuscitate (DNR) paperwork was present in the chart for a resident who requested DNR code status. This affected one (#52) of 19 residents reviewed for advance directives. The facility census was 47. Findings include:Closed record review for Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, diabetes mellitus, Alzheimer's disease, and seizures. Review of the physician's order, dated [DATE], revealed an order for the resident to be Do Not Resuscitate - Comfort Care Arrest (DNRCCA) code status. There was no DNR paperwork found in Resident #51's medical record. […]

• No harm, potential for more than minimal, isolatedF580Sep 18, 2025

  Based on record review, staff interviews, and facility policy review, the facility failed to ensure the physician was notified timely of a resident's change in condition. This affected one (#5) of one resident reviewed for notification of change in condition. The facility census was 47.Findings include: Record review for Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure, history of falling, difficulty walking, osteoporosis, and lack of coordination. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of the nursing notes on 05/23/25 at 5:59 A.M., Resident #5 had a witnessed fall. The resident reported pain of the right thigh. […]