Monroe Manor Health & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF835Apr 13, 2026

  Based on interview, record review, review of the facility's Director of Nursing's (DON) Job Description, and review of the facility's Administrator's Job Description, the facility failed to be administered in a manner that ensured residents attained and maintained their highest practicable physical, mental, and psychosocial well-being. The facility's Administrator and DON failed to identify and/or act on identified failures related to abuse and implementation of their abuse policy. These deficient practices affected four of 29 sampled residents (Resident (R) 44, R86, R21, and R90) reviewed for abuse. R86 was a cognitively intact resident who set relationship boundaries with R41; however, R41 crossed the boundaries and R86 sustained verbal sexual abuse. […]

• No harm, potential for more than minimal, patternF600Apr 13, 2026

  Based on observation, interview, record review, and review of the facility's abuse policies, the facility failed to ensure residents were free from abuse perpetrated by other residents. Specifically:(1) The facility failed to ensure Resident (R)86 was free from verbal abuse perpetrated when R41 put both his/her hands on both of his/her face cheeks and stated to him/her, I want to f*** you so bad.(2) The facility failed to assess R87, a cognitively impaired resident, for his/her capacity to consent before developing a care plan for resident's desire to engage in sexual expression.(3) The facility failed to ensure R44 was free from sexual abuse following an assessment of his/her capacity to consent to sexual contact using a facility assessment questionnaire that indicated R44 did not have… […]

• No harm, potential for more than minimal, patternF607Apr 13, 2026

  Based on interview, record review, review of the facility's policy, and review of the Code of Alabama the facility failed to implement the facility's abuse policies to ensure residents were free from all forms of abuse and failed to ensure their policy was developed to meet the minimum federal regulatory requirements related to sexual abuse, including residents' capacity to consent to sexual activity for two of 29 sampled residents, Resident (R) 44 and R87.Specifically, the facility failed to ensure R87, a cognitively impaired resident, was assessed for their capacity to consent before developing a care plan related to his/her desire to engage in sexual expression.In addition, the facility failed to ensure R44's assessment for capacity to consent was conducted in accordance with the… […]

• No harm, potential for more than minimal, isolatedF580Apr 13, 2026

  Based on interview, record review, and facility policy review, the facility failed to ensure the attending physician was immediately notified of a significant change in condition (low blood glucose levels) for one of one resident (Resident (R) 12) reviewed for notification of changes. R12 experienced repeated blood glucose levels ranging from 32 mg/dL (milligrams/ deciliter) to 44 mg/dL across multiple shifts without physician notification. This deficient practice resulted in a delay in medical evaluation and treatment.Findings include:Review of R12's Face Sheet located in the Resident tab of the electronic medical record (EMR) indicated admission on [DATE] with diagnoses including type two diabetes mellitus and multiple sclerosis.Review of R12's quarterly Minimum Data Set (MDS) located in… […]

• No harm, potential for more than minimal, isolatedF582Apr 13, 2026

  Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) notification was provided and that the responsible party was notified for two of three residents (Residents (R) 21 and R36) reviewed for beneficiary notification out of a total sample of 29 residents. This had the potential to affect all residents being discharged from services. Findings include:1.Review of R21's admission Record located under the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's and dementia.Review of R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/2025 and located under the MDS tab of the EMR, revealed a Brief Interview for… […]