Monroe Rehabilitation Center

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to communicate the facility's efforts to address concerns voiced by the Resident Council members and to resolve repeat concerns in 3 of the 14 Resident Council meeting minutes reviewed for Resident Council meeting grievances (12/10/2025, 01/14/ 2026, and 02/11/2026) and to maintain evidence that demonstrated the facility's response to grievances/recommendations made by the Resident Council from December 2025 through February of 2026.

Inspectors wroteBased 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. This occurred for 1 of 3 residents reviewed for abuse (Resident #1). [...]

Inspectors wroteBased on observation, record review, and staff, Contracted Pest Control Company Technician, and Wildlife Department Technician interviews, the facility failed to implement an effective pest control program to maintain a pest free living environment after the first sighting of a snake in the building on 8/15/2025 for 110 of 110 residents residing in the building.

Inspectors wroteBased on record review, and resident, staff and physician interviews, the facility failed to perform a physical assessment of a resident when Nurse Aide (NA) #3 reported to Nurse #2 and Nurse #3 on 9/2/2025 on the 3:00 pm to 11:00 pm shift the report of a fall and a change in Resident #2's self-transfer status from the wheelchair to the bed. Resident #2 was sent to the hospital on 9/3/2025 on the 7:00 am to 3:00 pm shift and admitted for a left hip fracture. This occurred for 1 of 1 resident reviewed for injury of unknown origin (Resident #2).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The NA indicated following incontinence care, he dressed the resident and transferred the resident back to his wheelchair as the resident continued to swing his arms and resist. [...]

Inspectors wroteBased on record review, observations, and staff and resident interviews the facility failed to provide a clean and sanitary environment for 16 of 16 resident rooms on the 200 hall (Rooms 208, 209, 211, 213, 215, 217, 218, 219, 220, 221, 222, 223, 224, 226, 228, and 233), 4 of 4 resident rooms on the 300 hall (Rooms 341, 355, 357, and 365), 8 of 8 resident rooms on the 100 hall (Rooms 103, 107, 113, 115, 120, 121, 130, and 134), 3 of 3 community restrooms on the 100 hall (rooms [ROOM NUMBER]), and 1 of 2 shower rooms on the 100 hall (room [ROOM NUMBER]).

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to label a medication stored on 1 of 7 medication carts (3W medication cart) and failed to remove expired medications on 2 of 7 medication carts (3W and 3E medication cart).

Inspectors wroteBased on observations, and staff and resident interviews and record review, the facility failed to provide a dignified dining experience when staff did not assist Resident #77 with his meal at eye level. This failure occurred for 1 of 4 sampled residents observed for dignity with dining.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to administer amantadine (a medication used for involuntary muscle movements or shaking) for 1 of 5 residents observed with medications at the bedside (Resident #110).

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to store a tube feeding syringe with the plunger separated from the syringe for 1 of 4 residents (Resident #95) reviewed for enteral feeding management, which created a potential for bacterial growth.

Inspectors wroteBased on record review, staff interviews, and observations the facility failed to provide an environment free of pests for 3 of 23 resident rooms (Resident #80, Resident #26, and Resident #86) and 1 of 3 community restrooms observed for roaches.

Inspectors wroteBased on observation and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, Complaint Intake, Adult Protective Services, the Office of the State Long-Term Care Ombudsman program, and the Protection and Advocacy network. This observation occurred for 3 of the 4 days during the onsite recertification survey.

Inspectors wroteBased on record review and resident, resident representative, and staff interviews, the facility failed to notify the Resident and the Representative in writing of the transfer to the hospital for 2 of 4 residents reviewed for hospitalization (Resident #29 and Resident #19).

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to provide portions of food per the menu. This had the potential to affect 35 residents with diet orders for regular texture diets, and 7 residents with diet orders for pureed texture diets.

Inspectors wroteBased on an observation, interviews with residents and staff and record review, the facility failed to provide palatable foods to 5 of 7 sampled residents per their preferences for temperature and taste (Residents #16, #29, #62, #363, and #365).

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to provide cheese ravioli with sauce according to the recipe to residents with diet orders for soft and bite sized foods. This failure had the potential to affect 16 of 111 residents with diet orders for soft and bite sized foods.

Inspectors wroteBased on record review, observations, resident, and staff interviews, the facility failed to notify the physician of the resident refusals to wear compression hose for 1 of 3 residents investigated for non-pressure related skin issues (Resident #24).

Inspectors wroteBased on record review, observations, resident, and staff interviews, the facility failed to document refusals to wear compression hose for 1 of 3 residents investigated for non-pressure related skin issues (Resident #24).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the resident and/or responsible party (RP) written notification of the reason for a hospital transfer for 2 of 2 residents reviewed for hospitalization (Residents #109 and #18).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide a written notification to the resident and the resident's representative regarding the facility's bed hold information when the residents were hospitalized for 1 of 2 residents reviewed for hospitalization (Resident #18).