Monette Manor, LLC

In the surveyor’s words

From the most serious findings on record at Monette Manor, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Apr 23, 2026

  Based on observation and interview, the facility failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control before taking the position. The failed practice had the potential to affect all 79 residents residing in the facility. The findings include: Review of the facilities Infection Prevention and Control Program (IPCP) states the facility must designate one or more individuals who are responsible for the facility IPCP who have the specialized training in infection prevention and control. […]

• No harm, potential for more than minimal, patternF881Apr 23, 2026

  Based on interviews and record review, the facility failed to maintain an infection prevention and control program that included an Antibiotic Stewardship Program (ASP) ) this failed practice had the potential to affect all residents who resided in the facility. The findings include: Review of an undated facility Antibiotic Stewardship Manual revealed that the Infection Preventionist (IP) will track antibiotic use and monitor adherence to evidence-based criteria and compile reports related to monitoring antibiotic usage and resistance data. Review of a facility Antibiotic Stewardship Tracking and Trending document revealed no documentation for the months of March and April of 2026. Last documentation for tracking/trending was February. […]

• No harm, potential for more than minimal, patternF656Dec 31, 2025

  Based on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure fall interventions were placed in a person-centered care plan following falls for five (Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9) of seven residents reviewed for fall interventions in a person-centered care plan. The findings include: Resident #4: A review of Resident #4's admission Record indicated the facility admitted the resident on 02/13/2024 with diagnoses which included a nondisplaced fracture of coracoid process, right shoulder (broken part of the shoulder blade), multiple rib fractures to the right side, and a wedge compression fracture of the T7-T8 vertebra (fracture to the middle of the spine). […]

• No harm, potential for more than minimal, patternF607Sep 26, 2024

  Based on observations, interviews, record review, document review, and facility policy review, the facility failed to report 3 of 3 incidents of resident-to-resident abuse reviewed, failed to report an unwitnessed fall with serious injury, and failed to complete a thorough investigation of the incidents. The findings are: 1. A review of an Admission Record indicated the facility admitted Resident # 46 with diagnosis Dementia, Severe with other Behavioral disturbance. The quarterly Minimum Data Set with an Assessment Reference Date 6/27/2024 revealed Resident # 46 had a Brief Interview for Mental Status (BIMS) score of 01 (0-7 suggest severe cognitive impairment). In Section E0200. Behavioral Symptoms revealed Physical behavioral symptoms directed towards others and B. […]

• No harm, potential for more than minimal, patternF640Sep 26, 2024

  Based on facility document review and interview, it was determined the facility failed to electronically transmit encoded, accurate, and complete, Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 6 (Residents #1, #2, #26, #34, #41, and #44) sampled residents whose MDS assessments were reviewed. The findings are: On 09/26/2024 the following observations were made in resident health records: Resident #1 had an Admission assessment with an ARD of 11/08/2023 exported but not accepted. Resident #2 had a Significant Change assessment with an ARD 1/28/2024 that was export ready. […]