Monroe Health Services

Inspectors wroteBased on observation and interview, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 43 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed food items in the freezer with visible freezer burn. Surveyor observed the facility's industrial stand mixer to be unclean. Surveyor observed an unclean ice bin. Surveyor observed staff sanitizing food thermometer with alcohol wipe without allowing it to dry before placing it in another food item during lunch service. Evidenced by: Facility policy, entitled General Food Preparation and Handling dated 8/16/22 states in part, . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the right to refuse a transfer to another room in the facility when the purpose of the move is solely for the convenience of staff for 1 of 5 residents (R41) reviewed for room changes. R41 was moved from one unit to another for the convenience of therapy staff without allowing the opportunity to refuse the transfer. This is evidenced by: Facility policy titled Private Rooms, implemented in 2/2018 and reviewed/revised in 07/2022, states, Procedure: Neither Medicare or Medicaid reimburse for a private room. If the facility has all private rooms, this is not an issue. However, when the facility has semi-private rooms, the resident will be admitted to a semi-private room unless the resident wishes to pay out of pocket privately or is deemed to require an isolation room related to an infection control issue. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 5 Residents (R46) reviewed for notification of change in condition. R46 had a heart rate above the facilities change of condition policy, and facility did not notify the physician timely. Evidenced by:The facility's Change in Condition of the Resident policy, dated 9/20/2022, states in part: Immediate Notification: Immediate notification for any symptom, sing or apparent discomfort that is: ii. A marked change in relation to usual symptoms and signs. Vital Signs, Pulse: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R3) reviewed for nutrition of a total sample of 13 residents. R3 has diagnoses including congestive heart failure and Stage 5 renal disease. R3 is dependent on renal (kidney) dialysis. Staff are not obtaining R3's daily weight per Physician orders. R3 had weight gain that was not reported to R3's provider. This is evidenced by:The facility does not have a policy and procedure for weights. The Facility policy, Change in Condition of the Resident, revised 9/20/22, documents the following, in part: A facility should immediately inform the resident; consult with the resident's physician; [...]

Inspectors wroteBased on interviews, record review, facility document review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of property for one of three sample residents (Resident (R) 1) reviewed for misappropriation.

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there was a need to alter treatment for 1 of 3 residents (R1) reviewed for physician notification. R1's provider was not notified of abnormal lab results. This is evidenced by: The facility policy titled, Change in Condition of the Resident, reviewed/revised 9/20/22, indicates, in part: Policy: A facility should immediately inform the resident; consult with the resident's physician .when there is .a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .3. Notify resident's physician - Use Interact Change in condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) as a guideline . [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, no later than 24 hours if the events that cause the suspicion do not result in serious bodily harm for 1 of 3 sampled residents reviewed (R10). R10 was found to have a injury of unknown origin (bruise) on her upper right arm on 7/7/24. This was not reported to the State Agency until 7/11/24. This is evidenced by: According to §483.12(c)(1) of the State Operations Manual; [...]

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive person-centered care plan for 1 sampled resident (R35) of 5 reviewed for unnecessary medications. Surveyor reviewed R35's comprehensive care plan. There is no care plan indicating the use of Melatonin for insomnia. The facility does not have a sleep assessment or sleep tracking for R35's Melatonin use. Evidenced by: The facility policy, entitled Comprehensive Care Plan, dated 9/23/22, states, in part: . POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for 1 of 1 Residents (R40) reviewed for weights out of a total sample of 16. R40 had an order for daily weights for seven (7) days. Weights were not completed 3 out of 7 days. Evidenced by: The facility policy, entitled Weight Monitoring, dated 12/21/22, states, in part: .The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.routine weights will be measured montly thereafter, unless ordered more frequently by the physician. Weights will be recorded in the individual's electronic health record. The nursing staff will notify the individual or responsible party, physician, and RDN (Registered Dietician Nutritionist) or designee of any individual with an unintended significant weight change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, or per resident's choice for 2 of 5 residents (R35 & R11) reviewed for non-pressure wounds and 1 of 5 residents (R15) reviewed for change in condition out of a total sample of 16 Residents. R35 has blanks on his Treatment Administration Record (TAR) indicating R35's wound care had not been completed. R35 sees the wound doctor weekly. On 5/2/24 the wound doctor had ordered a treatment to R35's left shin and the order did not get transcribed onto the TAR or completed. R11 had blanks on his TAR indicating R11's wound care was not completed on those days. R15 sustained a fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 1 of 2 residents reviewed for PIs out of a sample of 16 residents (R147). On 5/23/24 the wound doctor ordered Leptospermum honey (honey from the flowers of the Manuka bush) apply once daily for 23 days. Secondary Dressing: Gauze island with border apply once daily for 23 days for R147. This order did not get entered/transcribed onto R147's Treatment Administration Record (TAR) and was not completed as ordered on multiple days. Evidenced by: The facility's policy, entitled Pressure Injuries and Non pressure Injuries, dated 7/20/22, states, in part: .Policy: . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 34 opportunities that affected 2 out of 2 residents (R12 and R35) included in the medication pass task, which resulted in an error rate of 5.88%. RN C (Registered Nurse) did not assess the resident's heart rate or blood pressure prior to administration according to physician orders. LPN G (Licensed Practical Nurse) administered a medication with breakfast instead of one hour before breakfast according to physician orders. This is evidenced by: Facility policy entitled, Medication Administration, dated 01/2023, states in part: Policy: Medications are administered as prescribed in accordance with manufacturers' specifications . Procedures: Medication Preparation: . 3. [...]

Inspectors wroteBased on interview and record review the facility did not maintain medical records on each resident that are complete; accurately documented; readily accessible, and systematically organized for 1 of 16 sampled residents (R39) reviewed for fall risk. R39's medical record contains inaccurate fall risk assessments following five (5) falls within the facility over the span of three (3) months. This is evidenced by: R39 was admitted to the facility on [DATE] with diagnosis that include in part: encephalopathy (brain disease or dysfunction that causes and altered mental state), vascular dementia, and polyneuropathy (peripheral nerve damage causing weakness, numbness, and pain). R39's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/25/24, indicates a Brief Interview of Mental Status (BIMS) of 3 out of 15, indicating R39 is severely cognitively impaired. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 (R2) supplemental residents reviewed for antibiotic stewardship. R2 was given an antibiotic before all test results were returned and continued to take it after results despite lack of appropriate indications for its use. This is evidenced by: The facility policy titled, Antibiotic Stewardship Program, with a reviewed date of 1/24/24, indicates, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. [...]

Inspectors wroteBased on staff/resident interview and record review, the facility did not make prompt efforts to resolve grievances for 1 of 3 sampled residents (R1). R1 reported to DON B (Director of Nursing) multiple times regarding call light wait times and being left wet for long periods of time, as well as concerns regarding demeanor of two (2) staff members. DON B did not report these grievances to NHA A (Nursing Home Administrator), the Grievance Officer. Therefore, the grievances were not documented on the grievance log, and there is no documented follow-up with R1. The facility did not ensure prompt resolution of voiced grievances. As evidenced by: The facility's policy Grievance Policy, revised 7/2022, states as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 of 1 sampled residents (R1) reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R1 was admitted with an unstageable pressure injury (PI) to her right heel. Treatment orders were not completed as ordered.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (R1). R1's Physician Orders dated 1/17/24 indicate the following order: Decrease lasix to 20 mg (milligrams) twice daily. The facility did not enter the updated order nor administer the updated lasix dose until 1/19/24. This is a medication error. Evidenced by: The facility policy, Medication Administration, dated 1/2023, indicates, in part, as follows: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices Medications are administered in accordance with written orders of the prescriber. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure therapy services were provided for 1 of 6 residents (R1) reviewed for therapy services. R1 had an order for physical therapy (PT) and occupational therapy (OT) evaluation and treatment on discharge orders from hospital on 9/7/23. R1 was not evaluated and did not receive PT/OT services. This is evidenced by: R1 was admitted to the facility on [DATE] with diagnoses that include Calcinosis Cutis (a condition in which calcium salts are deposited in the skin and subcutaneous tissue), Type 2 Diabetes Mellitus (a condition that affects the way the body processes blood sugar. The body either doesn't produce enough insulin, or it resists it.), and Varicose Veins (gnarled, enlarged veins, most commonly appearing in the legs and feet) of Right Lower Extremity. R1's Hospital Discharge summary, dated [DATE], states, in part: . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 33 residents residing in the facility. Surveyor observed dust collecting on piping above food preparation area in the facility's stove hood unit. Surveyor observed a dust covered fan within 6 inches of food preparation area while food was being prepared. Surveyor observed a dust covered radio and desk top file folder holder above open prepared food. This is evidenced by: The facility policy, entitled Nutrition Services Practice Manual dated July 2015, states: .Promote a clean and sanitary environment for its employees, residents, and visitors. The entire nutrition services team maintains clean and sanitary kitchen centers and equipment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident with dignity and respect for 1 of 2 Residents (R5) reviewed for dignity out of a total of 16 residents sampled. R5 required staff assistance to meet her needs in toileting and her commode was left in her room with feces on and in the commode. R5 stated she was embarrassed when Surveyors conducted an interview.

Inspectors wroteBased on interview and record review, the facility did not consult with the Resident's physician for 1 of 2 residents (R13) reviewed for hospitalization of 16 sampled residents. R13 reported signs and symptoms of a Urinary Tract Infection (UTI) such as hematuria (blood in urine) and urgency to void to facility staff, and facility staff did not make attempts to contact the physician after the initial call was not returned. R13's Physician was not updated/consulted when R13 was not given all doses of her antibiotic. This is evidenced by: Facility policy titled Change in Condition of the Resident last reviewed on 9/20/22 states in part, .When a resident presents with a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning:1. Assess the resident's need for immediate care/ medical attention .2. Assess/ evaluate the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain grooming or personal hygiene for 1 of 3 residents (R3) that were reviewed for ADLs, out of a total sampled of 16. R3 did not have fingernail care completed and nails were noted to be long and sharp; food particles were observed on R3's face and R3's face was not shaved. This is evidenced by: The facility policy, entitled Activities of Daily Living (ADLs), dated 7/26/22, states in part: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . Policy Explanation and Compliance Guidelines: . 3. [...]