Monroe Manor

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. ensure a chemical restraint was not used to prevent a resident from eloping from the facility for 1 (#21) of 2 sampled residents reviewed for abuse; and b. ensure an as needed antianxiety medication order was limited to 14 days for 1 (#28) of 5 sampled resident reviewed for unnecessary medication. The administrator identified seven residents had been assessed at risk for wandering and elopement and two residents as a high risk for wandering and elopement. The DON identified two residents were prescribed PRN antianxiety medications.

Inspectors wroteOn [DATE] an Immediate Jeopardy (IJ) was determined to exist related to the facilities failure to provide appropriate tracheostomy care to include replacing a dislodged tracheostomy cannula. On [DATE] at approximately 5:30 a.m., agency nurse #1 entered Resident #1's room and discovered Resident #1's inner cannula had become dislodged and they were bleeding from the tracheostomy site. Agency nurse #1 failed to attempt to reinsert the inner cannula, provide oxygen, address the bleeding, and remain with the resident. On [DATE] at 12:13 p.m., the OSDH was notified and verified the existence of the IJ situation. On [DATE] at 12:23 p.m., the facility administrator was notified of the IJ situation. On [DATE] at 4:06 p.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal documented: 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to assess, monitor, and intervene for a resident who had increased pain from a fall resulting in a fracture of one (#2) of three sampled residents reviewed for falls. The DON identified the facility census was 38.

Inspectors wroteBased on record review and interview, the facility failed to perform an assessment and notify the physician of a dislodged PEG tube for one (#5) of three sampled residents reviewed for feeding tubes. The DON identified three residents in the facility with feeding tubes.

Inspectors wroteBased on record review and interview, the facility failed to: a) Ensure side effect monitoring was in place for one (#20) of five residents reviewed for unnecessary medications. b) Ensure PRN psychotropic medication orders are limited to 14 days for one (#26) of five residents reviewed for unnecessary medications. c) Ensure a gradual dose reduction recommendation was addressed by the physician for one (#9) of five residents reviewed for unnecessary medications. The DON identified 29 residents in the facility receiving psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure an unlocked container of ice was not utilized by residents and visitors. A facility Midnight Census Report, dated 08/10/24, documented 39 residents resided at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a) Have a system of surveillance and monitoring designed to identify and prevent Legionnaire's disease. b) Implement a policy and procedure related to enhanced barrier precautions. C) Ensure that infection control practices were followed during wound care for two (#32 and #15) of two residents reviewed for wound care. The administrator reported the census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was revised after a resident with a history of elopement attempts was observed by staff opening the facility's locked lobby door for one (#25) of twelve residents reviewed for care plan accuracy. A facility Midnight Census Report, dated 08/10/24, documented 39 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure influenza vaccinations were offered for two (#32 and #34) of five residents reviewed for immunizations. The administrator reported the census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident experiencing pain received treatment for pain for one (# 1) of four residents reviewed for pain. The administrator reported the census was 38.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the Oklahoma State Department of Health within the mandated time frame for one (#1) of three sampled resident reviewed for abuse. The DON reported the facility had a census of 39 residents.

Inspectors wroteBased on record review and interview, the facility failed to investigate an allegation of abuse and suspend an alleged perpetrator during the time of an investigation into the alleged abuse, for one (#1) of three sampled resident reviewed for abuse. The DON reported the facility had a census of 39 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify a resident's physician after a significant loss of weight for one (#2) of three sampled residents reviewed for weight loss. A Resident Listing Report documented 39 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with diabetes mellitus received necessary treatment and services that were consistent with the standards of practice for one (#1) of three residents reviewed for diabetic care. The administrator reported the census was 38.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement interventions to prevent falls/ minimize injuries for one resident (#1) of three sampled residents reviewed for falls. Resident #1 had 15 falls over 50 days. The last fall resulted in Resident #1 sustaining a facial laceration, hematoma, and their second subdural hematoma related to falls. The administrator reported the facility census was 38.

Inspectors wroteBased on observation and interview, the facility failed to ensure the dignity of a resident was protected for one (#1) of three residents sampled for dignity. The administrator reported the census was 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent: a. burns from hot coffee for two (#13 and #17) and b. falls for one (#37) of four residents reviewed for accidents. The Matrix for Providers documented 14 residents had fallen in the past 12 months and DON identified two residents had been burned from hot coffee within the past 12 months.

Inspectors wroteBased on record review and interview, the facility failed to ensure a dependent resident received baths for one (#37) of three sampled residents for bathing. The Resident Census and Conditions of Residents, dated 07/11/23, documented 39 residents required assistance with showers/baths.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure restorative therapy was performed for two (#27 and #34) of two sampled residents whose records were reviewed for restorative therapy. 1. Resident #27 had a diagnosis of quadriplegia. The March 2021 order summary report was reviewed. A physician's order designated as active, dated 08/13/18, documented the resident was to have restorative nursing perform range of motion therapy for both upper and both lower extremities 3 (to) 5 times each week. A review of the March 2021 MAR and TAR found no documentation that restorative therapy had occurred that month. A review of a documentation survey report for March 2021 found no documentation that restorative therapy had occurred that month. It did document the initials NA for the term non applicable had been entered on four dates that month. [...]