Monroe Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Monroe Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 21, 2025

  Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care in a manner to minimize/prevent accidents/injury for one resident (Resident #17-R17) in a survey sample of eighteen residents, which resulted in harm for R17. The findings included:1. For R17, the facility staff failed to transfer the resident with a mechanical lift in a manner to prevent accidents and injury, which resulted in a significant injury, which was harm. The facility self-identified the deficient practice and achieved past non-compliance on 10/9/24. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. […]

• Actual harm, isolatedF686Sep 22, 2021

  Based on observation, staff interview and clinical record review, the facility staff failed to assess and implement interventions to prevent a pressure ulcer for one of twelve residents in the survey sample, Resident #4. Resident #4 developed a sacral pressure ulcer initially identified as unstageable with necrotic tissue. There was no prior assessment of impaired skin on the sacrum. A nurse with knowledge of redness on the sacrum failed to document or report the redness prior to the development of the ulcer. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2026

  Based on observations, staff interviews, and facility document review, the facility staff failed to properly store, prepare and distribute food in the facility kitchen in a manner that would prevent foodborne illnesses.The findings included:The facility staff failed to maintain one of two kitchen freezers in proper working order, freezer #2 contained multiple food items that were not fully frozen. The facility staff had stacked wet pans nesting them while wet and a large scoop was stored inside an uncovered container of powdered thickener. There was a white cloth lying on the floor of the refrigerator and a roll of buffet ham was stored above produce, creating a risk of cross-contamination. […]

• No harm, potential for more than minimal, widespreadF925Aug 21, 2025

  Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective pest control program on three of three resident units and in the main kitchen and common areas of the facility. The findings included:On 8/19/25 at 1:55 p.m., a review of resident council minutes revealed that on 7/7/25, the resident council reported that Residents are seeing gnats and roaches. Both residents listed on the grievance lived on the 200 South unit. During the resident council meeting held Dec. 18, 2024, it noted . The group all mentioned an increase in cockroach sightings. In the September 2024 meeting it noted, . Resident [name redacted] stated he spotted a cockroach in his room by his bed recently. […]

• No harm, potential for more than minimal, patternF684Jul 21, 2022

  Based on a medication pass and pour observation, clinical record review, staff interview, facility document review, and during the course of a complaint investigation the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #39) and failed to accurately assess skin impairments for one of 27 residents (Resident #24). 1. The facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #95. 3. The facility staff failed to ensure transportation for outside rehabilitation appointments for Resident #11. 4. The facility staff failed to ensure transportation to an endocrinologist appointment for #39. 5. […]