Deficiencies (last 7 years)
Deficiencies (over 7 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
67% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to investigate infection prevention and control deficiencies related to hand hygiene and resident behaviors, triggered by concerns about staff monitoring and infection control practices.
Complaint Details
The investigation was complaint-related, focusing on infection prevention and control practices, specifically hand hygiene monitoring for Resident #6. The complaint was substantiated as staff failed to provide adequate hand hygiene and supervision.
Findings
The facility failed to ensure staff monitored and provided appropriate hand hygiene for a resident exhibiting behaviors that increased infection risk. The resident frequently had hands in pants and touched multiple items and other residents without staff intervention or hand hygiene assistance.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to ensure staff monitored and provided hand hygiene for a resident who repeatedly had hands in pants and touched multiple items and residents, increasing infection risk.
A4086 Infection Control/Communicable Disease: The facility did not meet the requirement to report communicable diseases to the division within seven days as required by Missouri regulations.
Report Facts
Facility census: 80
Days to report communicable disease: 7
Plan of correction completion date: Feb 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the statement of deficiencies and plan of correction |
| CMT E | Certified Medication Technician | Observed removing water pitcher without hand hygiene and not assisting resident with hand hygiene |
| CMT F | Certified Medication Technician | Reported difficulty keeping things sanitized due to resident's behaviors |
| Licensed Practical Nurse B | Licensed Practical Nurse | Reported difficulty with meal prep and service due to resident's behaviors |
| Director of Nurse | Director of Nursing | Reported efforts to educate staff on hand hygiene and infection control |
Inspection Report
Routine
Census: 80
Deficiencies: 1
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices related to a resident with dementia exhibiting inappropriate behaviors.
Findings
The facility failed to ensure proper hand hygiene for Resident #6, who frequently touched his/her genitals and then contacted multiple items and other residents without staff intervention. Staff did not consistently redirect the resident or perform hand hygiene, increasing the risk of infection transmission.
Deficiencies (1)
F 0880: The facility failed to provide and implement an effective infection prevention and control program. Staff did not ensure hand hygiene for Resident #6 who repeatedly touched his/her genitals and contaminated shared items without appropriate cleaning or redirection.
Report Facts
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT E | Certified Medication Technician | Did not assist Resident #6 with hand hygiene after touching a water pitcher and did not clean or replace the pitcher. |
| CMT D | Certified Medication Technician | Reported difficulty keeping things sanitized after Resident #6 touched items with hands down his/her pants. |
| CMT F | Certified Medication Technician | Reported Resident #6 kept hands down pants and constantly touched things, making sanitation difficult. |
| LPN B | Licensed Practical Nurse | Reported difficulty with meal prep and service due to Resident #6's behaviors and contamination risk. |
| Director of Nurse | Director of Nursing | Educated staff about hand sanitizing and keeping Resident #6's hands clean after touching genitals. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of residents' changes in condition and failure to follow physician orders for care and treatment.
Complaint Details
The complaint investigation found substantiated issues with failure to notify physicians of condition changes and failure to follow physician orders for care and treatment, including lab work and wound care.
Findings
The facility failed to notify physicians timely about changes in condition for two residents and failed to follow physician orders for lab tests, skin assessments, and dressing changes for three residents. Documentation of notifications and care was incomplete or missing.
Deficiencies (2)
F 0580: The facility failed to notify the physician when two residents had changes in condition, including increased confusion, abdominal distension, and behavioral symptoms, with no documentation of physician notification.
F 0658: The facility failed to ensure three residents received care per physician orders, including weekly skin assessments, obtaining ordered labs, and completing dressing changes as ordered, with documentation deficiencies noted.
Report Facts
Facility census: 68
Venous ulcer size: 4.5
Venous ulcer size: 2.4
Venous ulcer size: 5
Venous ulcer size: 0.6
Potassium level: 3
Potassium chloride dosage: 40
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to identify deficiencies in resident care and facility operations.
Findings
The facility failed to notify physicians timely about significant changes in residents' conditions and did not meet professional standards of care for three residents, including failure to complete skin assessments, follow physician orders, and obtain necessary lab tests. Deficiencies were documented related to notification of changes, comprehensive care plans, and nursing care standards.
Deficiencies (2)
F580 Notification of Changes: The facility failed to notify the physician when two residents had a change in condition, including increased confusion and abdominal distension, and did not document notifications in the medical record.
F658 Services Provided Meet Professional Standards: The facility failed to ensure three residents received care and services per physician orders and professional standards, including weekly skin assessments, obtaining labs, and following discharge orders.
Report Facts
Facility census: 68
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Life Safety
Capacity: 77
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri Department of Health and Senior Services on 03/20/2024.
Findings
The facility was found to be in compliance with emergency preparedness requirements but was found to be in noncompliance with Life Safety Code requirements related to the safe placement of compressed oxygen tanks near heating elements in the Cottage building.
Deficiencies (1)
K925 - The facility failed to ensure compressed oxygen tanks were a safe distance from heating elements in accordance with NFPA 99 (2012 edition) section 11.3.2.7. Observations revealed oxygen cylinders placed six and ten inches from heating elements in the Cottage building.
Report Facts
Occupied beds: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Indicated unawareness of the requirement regarding compressed oxygen tanks placement. | |
| Director of Nursing/ADON/Building & Grounds Supervisor | Responsible for monitoring effectiveness of corrective actions. |
Inspection Report
Recertification
Census: 73
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri Department of Health and Senior Services.
Complaint Details
The survey included a complaint investigation as part of the recertification process.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to catheterization orders and drug regimen review policies.
Deficiencies (2)
F690: The facility failed to ensure a physician's order was obtained to continue an indwelling urinary catheter for one resident. The catheter was placed during hospitalization but no current orders existed for its continuation.
F756: The facility failed to ensure the attending physician reviewed and acted upon pharmacist reports for one of five residents. The facility lacked proper documentation and rationale for not following pharmacy recommendations.
Report Facts
Survey Census: 73
Sample Size: 22
Supplemental Residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the statement of deficiencies and plan of correction |
| Certified Medication Technician 1 | CMT1 | Interviewed regarding catheter placement and resident condition |
| Assistant Director of Nursing | ADON | Interviewed regarding resident catheter use and staff communication |
| Director of Nursing | DON | Interviewed regarding catheter placement and physician orders |
| Attending Physician | Interviewed regarding medication rationale and catheter orders |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including catheter care and medication regimen review.
Findings
The facility failed to ensure a physician's order was obtained to continue an indwelling urinary catheter for one resident and failed to ensure the attending physician provided a rationale for not following the consultant pharmacist's recommendation regarding an anti-anxiety medication for another resident.
Deficiencies (2)
F 0690: The facility failed to obtain a physician's order to continue an indwelling urinary catheter for Resident 19, despite hospital instructions and care plan requirements.
F 0756: The facility failed to ensure the attending physician provided a rationale for disagreeing with the consultant pharmacist's recommendation to limit PRN psychotropic medication to 14 days for Resident 41.
Report Facts
Residents reviewed for catheters: 2
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) 1 | Interviewed regarding Resident 19's catheter care. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding Resident 19's catheter and staff waiting for physician approval. | |
| Director of Nursing (DON) | Interviewed regarding Resident 19's catheter orders and Resident 41's medication regimen. | |
| Attending Physician | Interviewed regarding rationale for medication decisions and catheter orders. |
Inspection Report
Plan of Correction
Census: 75
Deficiencies: 2
Date: Aug 12, 2022
Visit Reason
The inspection was conducted due to an infection control deficiency related to COVID-19 prevention and control measures, including an immediate jeopardy situation that was later removed.
Findings
The facility failed to implement appropriate infection control procedures to prevent the spread of COVID-19 among residents and staff. Specific failures included improper cohorting of residents by COVID status, inadequate use of personal protective equipment (PPE), and insufficient monitoring of residents for COVID-19 symptoms.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program to prevent the spread of COVID-19, including failure to separate COVID-positive residents from negative residents and improper use of PPE by staff.
A4086 Infection Control/Communicable Disease: The facility failed to report a communicable disease within seven days and did not meet infection control requirements, resulting in a Class I violation lowered to Class II.
Report Facts
Facility census: 75
Residents tested positive for COVID-19: 11
Residents monitored for COVID-19 symptoms: 7
Residents involved in cohorting failure: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Life Safety
Census: 70
Capacity: 119
Deficiencies: 4
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to ensure corridor doors resisted the passage of smoke and were positive-latching as required by NFPA 101. Electrical wiring and oxygen storage deficiencies were also noted, posing potential fire hazards.
Deficiencies (4)
K363 Corridor doors did not resist the passage of smoke and were not positive-latching as required by NFPA 101. A door to resident room 205 was missing a door knob/handle and did not latch properly.
K920 Electrical equipment wiring was not installed and maintained to prevent fire hazards in accordance with NFPA 70. A propane generator extension cord was improperly used year-round.
K923 Oxygen storage cabinets were not enclosed or secured properly, and oxygen cylinders were not stored according to NFPA 99 standards. Cabinets were made of combustible materials and oxygen tanks were unsecured.
K932 Clothes dryers in the facility had excessive lint buildup, creating a fire hazard. Maintenance cleaning was inconsistent and lint screens were not adequately maintained.
Report Facts
Facility capacity: 119
Resident census: 70
Residents potentially affected: 15
Residents potentially affected: 4
Residents potentially affected: 7
Residents potentially affected: 12
Inspection Report
Routine
Census: 70
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
Routine inspection to assess compliance with care planning, pressure ulcer care, catheter care, and medication administration standards.
Findings
The facility failed to develop and update comprehensive care plans for multiple residents, did not provide appropriate pressure ulcer care, failed to maintain proper catheter care leading to infection risks, and had medication administration errors related to enteral feeding tube practices.
Deficiencies (5)
F 0656: The facility failed to develop and implement complete care plans addressing residents' specific needs including smoking, oxygen therapy, pain, and wound care for four residents.
F 0657: The facility failed to update care plans within seven days of comprehensive assessments to reflect current care needs for four residents, including changes in diagnoses, treatments, and functional status.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for one resident, including failure to apply dressings timely and improper repositioning techniques.
F 0690: The facility failed to provide appropriate catheter care and prevent urinary tract infections for four residents with indwelling catheters, including improper catheter bag handling and inadequate perineal care.
F 0759: The facility failed to ensure medication error rates were below 5% when staff administered multiple medications together via a peg tube instead of separately as required.
Report Facts
Facility census: 70
Medication administration opportunities: 31
Medication administration errors: 3
Medication administration error rate: 9.68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in catheter care and medication administration observations and interviews |
| RN A | Registered Nurse (Wound Nurse) | Responsible for wound care and dressing application |
| CNA E | Certified Nurse Assistant | Observed performing catheter care and emptying catheter bag |
| CNA F | Certified Nurse Assistant | Observed performing catheter care and interviewed about catheter care practices |
| LPN D | Licensed Practical Nurse | Observed administering medications via peg tube and interviewed about medication preparation |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding care plan expectations, catheter care, and medication administration |
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
The document is a Plan of Correction submitted by Monroe Manor following a CMS inspection dated 04/28/2022, addressing deficiencies cited in the facility's comprehensive care plan, care plan timing and revision, treatment and services to prevent pressure ulcers, bowel/bladder incontinence, catheter, and UTI.
Findings
The facility failed to develop and update comprehensive care plans for multiple residents, did not provide ordered treatments to prevent pressure ulcers, and failed to ensure appropriate care for residents with urinary incontinence and indwelling catheters. Medication error rates exceeded acceptable limits.
Deficiencies (5)
F656 The facility failed to develop a comprehensive care plan for four residents, including addressing smoking, oxygen therapy, pain, and wound care. The facility census was 70.
F657 The facility failed to update interventions in residents' care plans to reflect current care needs for four residents. The facility census was 70.
F686 The facility failed to provide ordered treatments and prevent further tissue damage for a resident with pressure ulcers. The facility census was 70.
F690 The facility failed to ensure residents with urinary incontinence and indwelling catheters received appropriate treatment and services to maintain continence and prevent infections. The facility census was 70.
F759 The facility's medication error rate exceeded 5%, with an error rate of 9.68% for one resident. The facility census was 70.
Report Facts
Facility census: 70
Medication error rate: 9.68
Opportunities for medication errors: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the Plan of Correction document dated 5/20/2022. |
| Director of Nurses | DON | Referenced multiple times in interviews and plan of correction monitoring. |
| Assistant Director of Nursing | ADON | Referenced in wound care and plan of correction monitoring. |
| Licensed Practical Nurse B | LPN | Interviewed regarding resident smoking supervision and wound care. |
| Licensed Practical Nurse D | LPN | Observed medication administration and resident care. |
| Certified Nurse Assistant F | CNA | Interviewed regarding catheter care and resident transfers. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Date: Aug 20, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding quality of care concerns related to monitoring and reporting of a resident on Coumadin (blood thinner) therapy.
Complaint Details
Complaint investigation related to failure to monitor and report bleeding risks for a resident on Coumadin therapy. The complaint was substantiated as the facility lacked policies and failed to monitor and report appropriately.
Findings
The facility failed to follow professional standards of practice for one resident by not monitoring Coumadin precautions and not reporting abnormal bruising timely to the physician. There was no policy regarding Coumadin or bleeding precautions until after the resident was admitted to the hospital.
Deficiencies (2)
F684 Quality of care: The facility failed to monitor a resident on Coumadin for bleeding precautions and report abnormal bruising timely to the physician. No policy existed regarding Coumadin or bleeding precautions until after hospital admission.
A4074 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency at F684.
Report Facts
Resident census: 74
Date survey completed: Aug 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the statement of deficiencies and plan of correction |
| Assistant Director of Nursing | Interviewed regarding facility policies and resident care |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 3, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 1
Date: Nov 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted to assess the facility's infection prevention and control program compliance during the COVID-19 pandemic.
Findings
The facility failed to maintain an effective infection control program during the COVID-19 pandemic. Staff did not consistently use appropriate personal protective equipment (PPE), failed to post required signage, and did not encourage residents to wear masks outside their rooms.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to maintain an infection control program during COVID-19. Staff did not consistently use PPE, including eye protection, failed to post required signage, and did not encourage residents to wear masks outside their rooms.
Report Facts
Residents actively quarantined: 18
Residents sampled for review: 9
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Observed not wearing eye protection when working in COVID-19 positive resident rooms | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding PPE use and infection control practices |
| Certified Medication Technician (CMT) C | Certified Medication Technician | Observed administering medications without face shield or goggles |
| Certified Nurse Aide (CNA) D | Certified Nurse Aide | Observed not wearing face shield or goggles while assisting residents |
| Licensed Practical Nurse (LPN) G | Licensed Practical Nurse | Interviewed about PPE use and administering breathing treatments |
| Director of Nursing (DON) | Director of Nursing | Interviewed about mask policies and signage |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 75
Deficiencies: 6
Date: Mar 8, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Monroe Manor following a survey conducted on 03/08/2019. It addresses deficiencies found during the inspection and the facility's corrective actions.
Findings
The facility failed to provide care that ensured residents' dignity and individuality, failed to monitor and prevent falls effectively, and did not maintain an adequate infection prevention and control program. Specific issues included inappropriate staff behavior, inadequate fall prevention interventions, and lapses in infection control practices.
Deficiencies (6)
F550 Resident Rights: The facility failed to provide care that promoted residents' dignity and respect, including inappropriate staff language and cell phone use during care.
F689 Free of Accident Hazards: The facility failed to monitor and implement effective fall prevention interventions for residents at risk of falls, resulting in multiple falls and injuries.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection control program, including inadequate hand hygiene and improper handling of soiled linens and gloves.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. Refer to F689.
A4085 Infection Control/Communicable Disease: Residents shall be cared for using acceptable infection control procedures to prevent spread of infection. Refer to F880.
A8030 Dignity/Privacy: Each resident shall be treated with consideration, respect, and full recognition of dignity and individuality. Refer to F550.
Report Facts
Facility census: 75
Deficiency completion dates: Plan of correction completion dates set for 4/12/19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nursing | Interviewed regarding dignity policy and fall prevention | |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed about cell phone policy and resident care |
| Certified Nursing Assistant B | Involved in inappropriate language and care incidents | |
| Certified Nursing Assistant A | Interviewed about cell phone policy and resident care | |
| Certified Nursing Assistant P | Observed providing care and involved in infection control | |
| Licensed Practical Nurse L | Licensed Practical Nurse | Observed providing care and involved in infection control |
| Licensed Practical Nurse E | Licensed Practical Nurse | Observed providing care and involved in infection control |
| Licensed Practical Nurse J | Licensed Practical Nurse | Interviewed about fall incident |
| Licensed Practical Nurse O | Licensed Practical Nurse | Interviewed about resident fall risk |
| Nurse Assistant (CNA)/Activity Aide N | Interviewed about fall risk interventions | |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed about fall event reporting |
Inspection Report
Life Safety
Census: 75
Capacity: 107
Deficiencies: 10
Date: Mar 8, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to meet several Life Safety Code requirements including maintaining fire barriers, exit signage illumination, corridor door resistance to smoke passage, and proper use of electrical extension cords. Deficiencies had the potential to affect multiple residents across various smoke compartments.
Deficiencies (10)
K161: The facility failed to maintain the barrier between the first floor and attic space by not repairing openings in the ceiling to maintain a fire resistance rating of at least one hour. This deficient practice had the potential to affect 33 residents in three of nine smoke compartments.
K293: The facility failed to ensure exit signs were provided with continuous illumination, affecting 29 residents in two of nine smoke compartments.
K363: The facility failed to ensure corridor doors resisted the passage of smoke, potentially affecting 17 residents in one of nine smoke compartments.
K372: The facility failed to ensure smoke barriers in the attic were complete from outside wall to outside wall and floor to roof deck, potentially affecting 26 residents in four of nine smoke compartments.
K920: The facility failed to prohibit the use of extension cords and power strips beyond temporary installation, potentially affecting 12 residents in one of nine smoke compartments.
A2007: The facility failed to maintain noncombustible material between floors as required by regulation.
A2049: The facility failed to maintain exit and directional signs to be clearly legible and electrically illuminated at all times by acceptable means.
A2054: The facility failed to maintain smoke section walls and doors with required fire ratings and self-closing hardware to resist smoke passage.
A3027: The facility failed to restrict heating systems to approved types and prohibit portable heaters, with a portable space heater found in use. The facility census was 75.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
Report Facts
Residents potentially affected: 33
Residents potentially affected: 29
Residents potentially affected: 17
Residents potentially affected: 26
Residents potentially affected: 12
Facility census: 75
Facility capacity: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shari Embree | Administrator | Signed plan of correction and mentioned in interview regarding extension cords and portable heaters |
| Maintenance Staff R | Interviewed regarding ceiling inspections and extension cords | |
| Maintenance Staff S | Interviewed regarding Dutch doors and monthly door inspections | |
| Maintenance Staff T | Interviewed regarding attic inspections |
Inspection Report
Routine
Census: 75
Deficiencies: 3
Date: Mar 8, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to resident dignity, fall prevention, infection control, and medication administration in a nursing home.
Findings
The facility failed to provide care that ensured residents' dignity, failed to adequately monitor and prevent falls resulting in injuries, and failed to implement proper infection control practices including hand hygiene and glove use during personal care, wound care, catheter care, and medication administration through gastrostomy tubes.
Deficiencies (3)
F 0550: The facility failed to honor residents' rights to dignity and individuality, including inappropriate staff behavior and lack of a dignity policy.
F 0689: The facility failed to monitor and modify fall prevention interventions, resulting in multiple falls with injuries including fractures and lacerations for several residents.
F 0880: The facility failed to ensure proper infection prevention and control practices, including hand washing and glove use during personal care, wound care, catheter care, and gastrostomy tube medication administration.
Report Facts
Residents affected: 4
Residents sampled: 18
Facility census: 75
Pressure ulcers: 2
Medication administration rate: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Named in wound care and infection control deficiency observation |
| LPN E | Licensed Practical Nurse | Named in gastrostomy tube medication administration deficiency observation |
| CNA B | Certified Nurse Assistant | Named in perineal care and hand hygiene deficiency observation |
| CNA P | Certified Nurse Assistant | Named in catheter care and hand hygiene deficiency observation |
Inspection Report
Plan of Correction
Census: 81
Deficiencies: 2
Date: Jun 21, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to nutrition, hydration, and care for residents with swallowing difficulties at Monroe Manor.
Findings
The facility failed to provide adequate access to fluids for residents, resulting in dehydration risks. Observations showed residents lacked fluids within reach, staff did not offer drinks consistently, and hydration protocols were not properly followed.
Deficiencies (2)
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure residents had sufficient fluid intake and access to fluids, as evidenced by multiple observations of residents without fluids within reach and staff not offering drinks during care.
A4078 Sufficient Fluids/Hydration: The facility did not provide each resident the opportunity to access sufficient fluids to maintain proper hydration in accordance with medical orders and treatment goals.
Report Facts
Facility census: 81
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hydration Aide H | Named in observations and interviews regarding failure to pass thickened liquids to residents. | |
| Hydration Aide I | Named in observations and interviews regarding responsibility for passing water to residents. | |
| Registered Nurse K | Registered Nurse (RN) | Administered medication and observed not offering fluids to resident. |
| Licensed Practical Nurse E | Licensed Practical Nurse (LPN) | Interviewed about thickened liquid administration and resident care. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about staff responsibilities for providing thickened liquids and hydration. |
| Dietary Manager | Dietary Manager (DM) | Interviewed about preparation and provision of thickened liquids. |
Document
Deficiencies: 0
Visit Reason
This document is a Plan of Correction related to Life Safety Code deficiencies identified in a prior inspection.
Findings
The document outlines corrective actions to address Life Safety Code deficiencies but does not include new inspection findings.
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