Monroe Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 17, 2025

  Based on observations, record review, and staff, Medical Director, and Legal Guardian interviews, the facility failed to ensure Resident #1, who had cognitive impairment, was safely transported back to the facility following an orthopedic appointment on 4/08/25. Driver #1 failed to secure Resident #1's wheelchair to the van floor and secure Resident #1 in the wheelchair per the manufacturer's instructions during transport in the facility van. When Driver #1 drove out of the parking lot and turned right onto the main road, Resident #1 and the wheelchair she was in fell over to the left landing on the van floor. Driver #1 pulled over to the side of the road and observed Resident #1's head was bleeding and called 911. […]

• Immediate jeopardy, isolatedF760Nov 2, 2022

  Based on record review, interviews with staff, the facility physician and the Medical Director, the facility failed to administer the correct medications to a resident when Nurse #1 administered medications to Resident #7 that were prescribed for Resident #11. Resident #7 received 5 medications which included [MEDICATION(S)] (blood thinner), [MEDICATION(S)] (for nerve pain), [MEDICATION(S)] (for blood pressure), [MEDICATION(S)] (antidepressant) and [MEDICATION(S)] (for anxiety). Resident #7 was assessed by Nurse #1 on 9/6/22 at 12:10AM to have a heart rate of 48 and at 12:15AM a heart rate of 45. Resident #7 was transported to the Emergency Department (ED) for evaluation of altered mental status (AMS) and [CONDITION(S)] (low heart rate). […]

• Actual harm, isolatedF600Sep 30, 2025

  Based on record review, observation, and resident, resident representative, staff and physician interviews, the facility failed to protect a resident's right to be free from mental abuse and humiliation when Nurse Aide (NA) #1 continued to provide personal care to Resident #1 after Resident #1 was heard saying calmly leave me alone in an electronic video that NA #1 recorded with NA #1's personal cellular phone device while providing personal care to a resident (Resident #1). On the electronic video, Resident #1's chest area was observed exposed with no clothing or linens covering Resident #1's chest area. Resident #1's behaviors were observed escalating from a calm verbal tone to cursing and physically swinging her left arm at NA #1. […]

• Actual harm, isolatedF600Jan 8, 2025

  Based on record review, and staff, family member, and physician interviews, the facility failed to protect Resident #87's right to be free from staff to resident abuse perpetrated by Nurse Aide (NA) # 1. During care, Resident #87 sustained a bruise to the left eye with pain when touched, a bloody nose, a 3-millimeter (mm) skin tear to the left elbow, and a scratch and discoloration to the left cheek. NA #1 stated Resident #1 was fighting me like crazy when he transferred the resident to bed from his wheelchair to provide incontinence care. The NA proceeded to force care upon Resident #87 as the resident remained combative and resistive to care, swinging his arms at the NA's face. […]

• No harm, potential for more than minimal, widespreadF880Oct 26, 2021

  Based on record reviews, observations, staff interviews and the high level of transmission for COVID-19 in the county, the facility failed to screen facility surveyors and visitors for signs and symptoms of COVID-19 before entering the facility 4 of 4 on-site survey days and 1 of 1 nurse (Nurse #4) was observed administering a gastrostomy tube feeding nutritional bolus to Resident #17 without gloves. Additionally, the facility failed to revise their infection control policies and implement the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 5 of 5 staff members (Nurse Aide #1, Nurse #4, Nurse Aide #3, Nurse Aide #2 and Nurse #2) in the general halls failed to wear eye protection while providing care to 6 of 6 residents… […]