Monroe Springs Skilled Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Monroe Springs Skilled Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 24, 2026

  This citation pertains to intake 3037808.Based on interview and record review the facility failed to provide adequate supervision from two staff members during a transfer with a mechanical lift for one (R507) of five residents reviewed for accident hazards/safety resulting in R507 falling off the lift during transfer, hitting their head, and requiring five staples for wound closure.Findings include:The State Agency (SA) received a complaint that R507 fell from a mechanical lift and sustained injuries.According to the Electronic Health Record (EHR) R507 admitted to the facility in 2019 with multiple diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2023

  Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 79 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 80 residents. Findings include: 1. On 11/14/23 at 3:04 PM, an accumulation of dust, ice, and food debris was observed on the floor of the walk-in freezer. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. We do a deep clean in here monthly. […]

• No harm, potential for more than minimal, widespreadF725Jan 25, 2023

  This citation pertains to MI00128672. Based on observation, interview, and record review the facility failed to staff the third floor to meet the needs of 12 residents (R68, R27, R64, R56, R38, R67, R59, R8, R29, R41, R5, and R66) of 20 residents reviewed for staffing concerns resulting in untimely/incomplete incontinence care, no set-up assistance for personal care, limited assistance with activities of choice, inconsistent supervision, and concerns with safety with subsequent refusal of care. Findings include: On 1/22/23 during the initial tour at approximately 10:30 AM, of the 20 residents on the third floor, two residents (R67 and R68) were observed in the dining/day room area with the television on and unsupervised. […]

• No harm, potential for more than minimal, widespreadF809Jan 25, 2023

  This citation pertains to intake MI00128788. Based on interview and record review, the facility failed to consistently ensure no more than 14 hours occurred between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, resulting in the potential for resident dissatisfaction and unmet care needs for all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding timely meal service. On 1/22/2023 at approximately 11:07 AM, during a meeting with the Nursing Home Administrator (NHA), a CMS (Centers for Medicare & Medicaid Services) document titled, Entrance Conference Worksheet was reviewed which listed information requested from the facility. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2023

  Based on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Properly date-label opened food; 3. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked penne, mashed potatoes, and meat cutlets; 4. Ensure ladles were stored properly to prevent contamination; 5. Consistently log the temperature of the high-temperature sanitizing dish washing machine; and 6. Removed expired, undated, unlabeled food from a resident refrigerator. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. […]