Monroe Rehabilitation Center

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1 was told by the facility to delete the video recording of Resident #1 that Caller #1had uploaded onto her personal cellular device and use to report to the facility. The Administrator stated NA #1 had reported during her interview, she had already deleted the recorded video of Resident #1 from her personal cellular phone device. He further stated neither Caller #1 nor NA #1 had been to the facility as requested to verify the recorded video of Resident #1 had been deleted from their personal cellular phone devices.On 9/24/2025 at 12:18 pm in a phone interview with Caller #1, she stated as instructed by the facility, she had deleted the recorded video of Resident #1 that she had uploaded to her personal cellular phone device on 9/9/2025.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Rehabilitation Center

1212 Sunset Drive East Monroe, NC 28112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Director of Nursing and presented to the Quality Assurance Performance Improvement committee monthly.

Based on the audit results, the Quality Assurance Performance Improvement committee will determine the need of further monitoring for residents with a change in condition for mobility/transfers. Compliance Date: 9/8/2025 On 9/12/2025, the facility's corrective action plan was validated by the following documentation: Residents' EMR for change in condition the past 2 weeks were reviewed by Assistant Director of Nursing

on 9/5/2025 with no concerns identified. Physician orders in residents' EMR were reviewed for the past 2 weeks by the DON on 9/5/2025 with no concerns identified. The physician communication book was reviewed for the past 2 weeks by the DON 9/5/2025 with no concerns identified. Incident reports for the past 2 weeks were reviewed by the DON 9/5/2025 with no concerns identified. Body audits for residents with a BIMS less than a 12 were assessed to identify changes in mobility and transfer status and notification of physician and resident representative by the Assistant Director of Nursing and unit managers

on 9/6/2025 with no change or injury identified. Residents with a BIMS greater than 13 were interviewed for changes in mobility and transfer status by the Assistant Director of Nursing and DON on 9/5/2025 with no falls identified and not reported to the nursing staff. Educational sign in sheets starting 9/3/2025 recorded nursing staff ( nurses and nurse aides) received education in-services on change of condition, recognizing and assessing a change in resident and notifying the nurse and notification of the physician of a change in resident's condition. Interviews with the nursing staff verified education in-services were conducted for the nursing staff as indicated in the POC. The facility's compliance date was validated as 9/8/2025.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Rehabilitation Center

1212 Sunset Drive East Monroe, NC 28112

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

approximately 6-inch small snake was observed on 8/25/2025 around 9:00 pm in the hallway at the dining room door nearest to the residents' rooms. Nurse #1 stated she was from the country and new the snake was a copperhead. She explained another unknown named staff member gathered the snake in a box and removed the snake from the facility. Nurse #1 stated there were no residents around the snake and she notified the Administrator and the DON via text of the snake sighting. The distance from the closest resident room to the closest door of the dining room measured 63 feet. In an interview with the DON on 9/10/2025 at 4:39 pm, she stated Nurse #1 notified her via a group text that included the Administrator on 8/25/2025 at 9:00 pm of a snake at the door of the dining room. The DON stated when the Administrator requested Nurse #1 to send him a photo of the snake, Nurse #1 stated the snake had already been removed by a staff member and the Administrator reported the contracted pest control technician had been to the facility and treated the building on 8/25/2025. In an interview with the Administrator on 9/11/2025 at 12:35 pm, he stated on 8/25/2025 the Contracted Pest Control Company Technician had informed the receptionist that

the wildlife department had been notified to treat for snakes in the building. He stated on 8/26/20205 the building was inspected exteriorly by the Maintenance Director, and an interior inspection was conducted by

the Administrator with no further snake findings reported. In an interview with the Maintenance Director on 9/11/2025 at 3:10 pm, he stated the facility did not have snake repellent materials to applied exteriorly to

the building. A Wildlife Department report dated 8/29/2025 recorded the building was surveyed interiorly and exteriorly and there were no snakes removed from the building. The wildlife department technician recorded snake deterrent was applied around every door of the building to prevent future entry of snakes. In

a phone interview with the Wildlife Department Technician on 9/12/2024 at 12:22pm, he stated on 8/29/2025 there were no snakes or mice observed in the building and snake deterrent material was applied around the doors exteriorly. He explained snake deterrent materials were not applied in the interior of the building and encouraged the facility to keep the exterior grounds and interior rooms and offices clean to deter pest that may attract snakes. He explained snake deterrent treatment should last for 4-6 months and

the facility should consider retreating with a snake deterrent in the springtime. In an interview with the Administrator on 9/11/2025 at 12:35 pm, he explained there was not a resident safety concern because when the snakes were observed in the building, the snakes were not close to a resident and were disposed of immediately. He stated there had been no further sighting of snakes in the building since the wildlife department technician applied deterrent outside the building around the doors. In an interview with the Regional [NAME] President of Operations on 9/11/2025 at 12:40 pm, he stated there was a repairman scheduled to come to the facility on 9/11/2025 to close the half inch opened space area between the two front entrance doors where pests could enter the building. On 9/12/2025 at 2:30pm, the front entrance doors were observed with the half inch open space at the bottom when the two front doors were closed.

There was enough space for a snake to enter the building.

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