Monroe Manor

In the surveyor’s words

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

• Immediate jeopardy, patternF880Aug 12, 2022

  Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading the virus [CONDITION(S)]-CoV-2, (a coronavirus discovered in 2019), which causes COVID-19 infection (an infectious disease caused by severe acute respiratory syndrome), when the facility failed to separate five residents (Residents #2, #9, #11, #14, and #16), who tested negative for COVID-19, from their roommates (Residents #1, #8, #12, #13, and #15), who tested positive for COVID-19 infection. […]

• Actual harm, isolatedF684Aug 20, 2021

  Based on interview and record review, the facility failed to follow professional standards of practice for one resident (Resident #1) of five sampled residents when staff failed to monitor the resident for [MEDICATION(S)] (blood thinner used to treat and prevent blood clots) precautions, and report abnormal bruising in a timely manner to the physician. The census was 74. Record review of Nursing 2020 drug handbook, copyright 2020 showed the following: -Wafarin sodium ([MEDICATION(S)]) (anticoagulant) (blood thinner); -PT (prothrombin time, a blood test to evaluate blood clotting) and INR (international normalized ratio, a blood test used to monitor how well the blood-thinning medication, [MEDICATION(S)] is working) determinations are essential for proper control; -Adverse reactions… […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  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,… […]

• No harm, potential for more than minimal, patternF880Jan 14, 2025

  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. […]

• No harm, potential for more than minimal, patternF658Nov 12, 2024

  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. […]