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, isolatedF695Sep 23, 2024

  On [DATE] an Immediate Jeopardy (IJ) was determined to exist related to the facilities failure to provide appropriate tracheostomy care to include replacing a dislodged tracheostomy cannula. On [DATE] at approximately 5:30 a.m., agency nurse #1 entered Resident #1's room and discovered Resident #1's inner cannula had become dislodged and they were bleeding from the tracheostomy site. Agency nurse #1 failed to attempt to reinsert the inner cannula, provide oxygen, address the bleeding, and remain with the resident. On [DATE] at 12:13 p.m., the OSDH was notified and verified the existence of the IJ situation. On [DATE] at 12:23 p.m., the facility administrator was notified of the IJ situation. On [DATE] at 4:06 p.m., an acceptable plan of removal was submitted to the OSDH. […]

• Actual harm, isolatedF684Sep 23, 2024

  Based on record review and interview, the facility failed to assess, monitor, and intervene for a resident who had increased pain from a fall resulting in a fracture of one (#2) of three sampled residents reviewed for falls. The DON identified the facility census was 38. Findings: An undated facility document titled Fall Prevention Policy, read in part, .If a resident experiences a fall, the charge nurse will complete an Incident Report and document the fall in the resident's record, as well as the 24-hour report. […]

• Actual harm, isolatedF684Jan 23, 2024

  Based on record review and interview, the facility failed to ensure a resident with diabetes mellitus received necessary treatment and services that were consistent with the standards of practice for one (#1) of three residents reviewed for diabetic care. The administrator reported the census was 38. Findings: Resident #1 had diagnoses which included diabetes mellitus and cysts of the pancreas. A baseline care plan, dated 11/25/23, did not document the resident was diabetic. A physician order, dated 11/26/23, documented the resident was to be given glimepiride (a diabetic medication) 4 mg by mouth once a day. An admission MDS, dated [DATE], did not document the resident was diabetic. […]

• No harm, potential for more than minimal, patternF605Jun 23, 2026

  Based on observation, record review, and interview, the facility failed to: a. ensure a chemical restraint was not used to prevent a resident from eloping from the facility for 1 (#21) of 2 sampled residents reviewed for abuse; and b. ensure an as needed antianxiety medication order was limited to 14 days for 1 (#28) of 5 sampled resident reviewed for unnecessary medication.The administrator identified seven residents had been assessed at risk for wandering and elopement and two residents as a high risk for wandering and elopement. The DON identified two residents were prescribed PRN antianxiety medications.Findings:1. A video recording of the dining room, dated 05/31/26 at 4:37 p.m. through 05/31/26 at 4:42 p.m., showed the following:a. […]

• No harm, potential for more than minimal, patternF758Aug 14, 2024

  Based on record review and interview, the facility failed to: a) Ensure side effect monitoring was in place for one (#20) of five residents reviewed for unnecessary medications. b) Ensure PRN psychotropic medication orders are limited to 14 days for one (#26) of five residents reviewed for unnecessary medications. c) Ensure a gradual dose reduction recommendation was addressed by the physician for one (#9) of five residents reviewed for unnecessary medications. The DON identified 29 residents in the facility receiving psychotropic medications. Findings: 1. […]