Monroe Health & Rehab Center

F 0554

Allow residents to self-administer drugs if determined clinically appropriate.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, resident interview, staff interview, clinical record review, and facility documentation

review the facility staff failed to assess a resident's ability to safely self-administer medications for one resident, Resident #9 (Resident R9) out of a survey sample of 18 residents. The findings included:Facility staff allowed Resident R9 to keep medication at the bedside for self-administration without completing a self-administration assessment.On 8/19/25 at 11:10 a.m., an observation was conducted of medications at Resident R9's bedside. At that time, an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 were observed in a basket.On 8/19/25 at 11:15 a.m., an interview was conducted with Resident R9 regarding the medications observed. Resident R9 stated that she keeps the pain ointments in her room because she was undergoing chemotherapy and uses them for pain relief. Resident R9 then said, I take my inhaler twice a day and the nurse brings it in here in the morning and leaves it with me to take it in the morning and at bedtime.On 8/19/25 at 11:40 a.m., an interview was conducted with a licensed practical nurse, LPN#1 (LPN1). LPN1 stated that there was a form completed for residents to be approved to self- administer medications. She further stated, skilled residents sometimes bring in their own medications and we don't know anything about it. If I was to see the medications, I would remove the medicine and explain why we were not allowed to leave medicine at the bedside.On 8/19/25 at 12:45 p.m., an interview was conducted with unit manager

on unit one, LPN#2 (LPN2). LPN2 stated that she thought Resident R9 had a self-administer assessment completed and was not aware that one had not been done. She explained that medicines found in the room that morning severed as a prompt to complete an assessment. She reported she was under the impression an assessment had already been completed due to Resident R9's pain needs. LPN2 stated that she told Resident R9 she was going to speak with the physician about having the medications at bedside, and then she completed a self-administration assessment.On 8/19/25 at 1:00 p.m., a follow-up observation was conducted in Resident R9's room. The inhaler remained in the basket at the bedside. The self-administration form had been completed by LPN2; however, no locked compartment was observed for the medication storage.A review of Resident R9's clinical record revealed there was no self-administration assessment completed prior to medications being left at bedside. Resident R9's care plan had not addressed self-administration of medications for pain or inhaler use.

The Minimum Data Set did not reflect that Resident R9 was independent with medications.A review of facility documentation was conducted. The facility policy titled, Self-Administration of Medications, read in part, .3.

To ensure safe and appropriate self-administration, facility should educate residents to ensure that a resident is able to: 3.1 state the name, dose, strength, frequency and purpose for use of their medications. 3.2 Understand the possible medication side effects and that they should notify facility staff if they experience any such side effects. 3.3 correctly administer, inject, or apply all prescribed medications. 3.4 correctly store their medications in a locked compartment.On 8/20/25 at approximately 4:00 p.m., an end of day meeting was held with the Regional Director of Clinical Services, [NAME] President of Operations and Director of Nursing. They were made aware of the concerns above.No additional information was provided.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on staff interviews and clinical record review the facility failed to ensure reasonable care for the protection of personal property for one of eighteen residents, Resident #3 (Resident R3). Resident R3 did not have a personal property invoice completed upon admission to help track valuables. The Findings Include:Diagnoses for Resident R3 included contusion of left lower leg, status post left knee surgery, obesity, depression, kidney disease, and deep vein thrombosis. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 08/1/2024. Resident R3 was assessed with a cognitive score of 15 indicating cognitively intact.Resident R3 was reviewed due to a report of possible missing medication (Ozempic brought from home to the facility) and two gift cards.Review of Resident R3's clinical record did not evidence an inventory form had been filled out upon admission or at any time during Resident R3's stay at the facility.On 8/19/25 at 2:30 p.m. license practical nurse (LPN #7) was interviewed regarding documentation of resident's inventory list. LPN #7 explained when a resident is admitted an inventory form is filled out. Review of the facilities grievance logs indicated that Resident R3 had reported missing gift cards on 7/22/24 and indicated the concern was being investigated by license practical nurse (LPN #2, unit manager).On 8/19/25 at 3:00 p.m. the director of nursing (DON) was interviewed regarding Resident R3's missing inventory list. The DON said that she would look for it.On 8/20/25 at 10:30 a.m. the DON verbalized Resident R3 inventory list could not be found. The DON stated that

she would not list medications on a personal property list but would put the medication in the refrigerator with the resident's name on it. On 8/20/25 at 11:50 a.m. The DON was able to evidence through pharmacy records that Resident R3's personal Ozempic was used by the facility and then was being filled by the pharmacy. On 8/20/25 at 12:00 p.m. LPN #2 (who investigated the missing gift cards) was interviewed. LPN #2 was able to evidence via Concern Form that Resident R3's gift cards were replaced by the facility. The DON presented a personal property policy that read in part The facility will take reasonable care to prevent loss, or theft of, resident's personal property while residing at facility [.]. No other information was presented prior to the exit conference on 8/21/25.

Event ID:

Facility ID:

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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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

[the hospital] didn’t even do an x-ray which I thought was odd, they put two big ace bandages on it and when I got back they [the facility staff] decided I needed to go back and I was sent to [different hospital name redacted], they confirmed it was a hematoma and also found other issues that were not related to the fall and kept me for several days.”

On 8/21/25, in the morning, an interview was conducted with the director of nursing. She reported that the skin tear was “superficial” and therefore no detailed documentation was made into the clinical

record other than the treatment orders noted above.

The facility's policy titled Incident/Accident Policy (revised 10/1/24) documented, .Documentation/assessment post-incident will be completed, including neurological assessment when indicted [indicated]. Further assessments will be conducted as ordered by the provider or as indicated by nursing judgement .

The facility's policy titled Pressure Injury Prevention and Treatment Policy - Skin and Wound Care (revised 9/18/23) documented, .Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. Other wound types will be assessed every shift to determine presence of ordered dressing and wound characteristics if observable .All assessments will include the following elements .Location .Size .Exudate .Pain .Wound bed .Color and type of tissue .Appearance of surrounding tissue .Any evidence of infection .

The Lippincott Manual of Nursing Practice 11th edition on page 15 documents regarding common departures from the standards of nursing care, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events .

On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed.

No additional information was provided. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.

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

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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

clinical record, she stated that providers do not enter orders; nurses enter them.No additional information was provided.

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

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

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

Given my concern r/t [related to] his chronic anticoagulation and hematoma development, and subsequent blood loss, I strongly encouraged the patient to consider being sent out via EMS [emergency medical services] to the ED [emergency department] for emergent evaluation +/- x-ray imaging and blood testing.

He agreed to going out. On 8/21/25 at 10 a.m., the DON was again asked about the hospital records and stated they were working to obtain them. The surveyor asked the medical director if he had access to the records and he said he did not, that perhaps the resident or his spouse could access the records. On 8/21/25 at 10:30 a.m., the surveyor met with the DON and asked if she had a QAPI plan for the incident involving Resident R17 for the 7/29/25 incident like she had for the incident in October 2024. The DON stated that

she did not and stated, the skin tear was superficial. When asked about an x-ray, the DON stated that the resident refused so no x-ray was obtained at the facility. On 8/21/25 at 10:45 a.m., the survey team met with

the facility administrator, DON, and corporate staff to review the above findings. They reported they had no further information to provide. The assistant director of nursing confirmed they had reached out to the hospital to obtain copies of the records from where Resident R17 had been sent to the hospital on 7/29/25. When asked if they had reached out to the hospital prior to that day, when the surveyor started asking for the documents, the assistant director of nursing stated, not that I am aware of. All of the administrative staff in attendance confirmed that the expectation would have been for the hospital records to be contained within Resident R17's clinical record. On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, resident interview, staff interview, clinical record review, and facility documentation

review the facility staff failed to administer oxygen per physician's orders, and to date and label oxygen tubing and humidifier bottle for one resident, Resident #10 (Resident R10) out of a survey sample of 18 residents.The findings included:Resident R10 was not being administered her ordered oxygen, and the oxygen tubing and humidifier bottle were not labeled with a date of placement.On 8/19/25 at 11:10 a.m., an

observation of Resident R10 revealed that oxygen was not being administered as ordered. The oxygen concentrator was observed in the resident's room with the humidifier bottle sitting on the floor. There was no oxygen tubing connected to the concentrator. During the observation, Resident R10's spouse was present in the room, stated that the resident had not had the oxygen on since the previous day when it was removed and the oxygen tubing was taken out of the room. A subsequent observation of Resident R10 on 8/19/25 at 2:45 p.m., again revealed that oxygen was not being administered per the physician's order.On 8/19/25 at 2:45 p.m., an

interview was conducted with the unit one manager, licensed practical nurse, LPN#2 (LPN2). LPN2 was asked to review Resident R10's oxygen order and stated that the order was for two liters per nasal cannula, continuous. LPN2 then entered Resident R10's room and was observed looking at the oxygen concentrator. The concentrator had tubing and humidifier bottle present; however, the tubing was stored in a bag and there were no dates or labels on the tubing or the humidifier bottle. At the time of the observation, Resident R10 was still not receiving oxygen as ordered.During this observation with LPN2 on 8/19/25 at 2:45 p.m., Resident R10's spouse, who was in the room, told LPN2 that the tubing from the oxygen concentrator had been removed the previous day. He further stated that they were planning to keep a check on the resident's oxygen levels, and that no staff had come in to check since he had been present that morning. Resident R10 was still not receiving oxygen per order.On 8/19/25 at 4:00 p.m., another observation showed Resident R10 still was not receiving oxygen.

At that time, LPN1 was observed checking Resident R10's oxygen saturation, which measured 94%. Earlier that morning, the oxygen saturation had been documented at 98%. On 8/19/25, a review of Resident R10's clinical record revealed a physician's order for oxygen to be administered vis nasal cannula continuously at tow liters.

Documentation showed the order had been signed off that morning as having been administered. Review of Resident R10's care plan reflected the same instructions for continuous oxygen at two liters via nasal cannula. On 8/20/25, a facility document was reviewed. The facility documentation titled, Oxygen Administration (all routes) Policy, read in part, .licensed clinicians with demonstrated competence will administer oxygen via

the specified route as ordered by a provider. On 8/20/25 at approximately 4:00 p.m., an end of the day meeting was held with the regional director of clinical services, vice president of operations and director of nursing. They were made aware of the concerns above.No additional information was provided.

Residents Affected - Few

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

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

fall from his bed. Nursing reported to me that the patient rolled off his bed and onto the floor as personal care was being performed around 12:00 s/p having had a bowel movement. He reportedly fell onto the floor landing on his left lower extremity; he apparently did not hit his head. I did notice swelling on the lateral distal left thigh/knee area which appeared to be a hematoma.I marked the affected area with a pen establishing an area of 19 cm along the distal lateral femur and 14 cm wide transverse to the leg on my initial visit. I discussed the value of XR [x-ray] imaging to rule out any type of fracture. The patient refused having the leg imaged at this time. I spoke with nursing and ordered to keep the leg elevated, and to apply

an ice pack. I promised to return in about an hour to re-evaluate the hematoma and developing situation. I re-examined the patient at 15:30. The patient was in no acute distress, but clearly uncomfortable and appeared frustrated. My examination revealed expansion of the hematoma now to 21 cm long x 18 cm wide. Given my concern r/t [related to] his chronic anticoagulation and hematoma development, and subsequent blood loss, I strongly encouraged the patient to consider being sent out via EMS [emergency medical services] to the ED [emergency department] for emergent evaluation +/- x-ray imaging and blood testing. He agreed to going out. On 8/21/25 at 10 a.m., the DON was again asked about the hospital records and stated they were working to obtain them. The surveyor asked the medical director if he had access to the records and he said he did not, that perhaps the resident or his spouse could access the records. On 8/21/25 at 10:45 a.m., the survey team met with the facility administrator, DON, and corporate staff to review the above findings. They reported they had no further information to provide. The assistant director of nursing confirmed they had reached out to the hospital to obtain copies of the records from where Resident R17 had been sent to the hospital on 7/29/25. When asked if they had reached out to the hospital prior to that day, when the surveyor started asking for the documents, the assistant director of nursing stated, not that I am aware of. All of the administrative staff in attendance confirmed that the expectation would have been for the hospital records to be contained within Resident R17's clinical record. On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided.

Event ID:

Facility ID:

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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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monroe Health & Rehab Center

1150 Northwest Drive Charlottesville, VA 22901

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 - Many

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

pest entry. During the tour it was noted that there were two sets of double doors for entry into the lobby and both had visible gaps which would allow pests to enter. The EVSD reported he has put weather stripping on

the doors to seal the gaps, but wheelchairs tend to knock it off. On 8/19/25 at 3:20 p.m., a tour of was conducted of the kitchen with the EVSD. According to the pest control reports it noted cracks or damage to wall behind dishwasher allowing pest access, was a high area of concern since April 15, 2025. Also noted

in the pest control report dated 7/16/25, it read, wall around the dishwasher machine needs to be removed and clean all the food and standing water from inside the wall, also sealed opening around pipes, wall and floor, we recommend this so many time [sic]! During the tour of the kitchen, it was noted that in the dish room there was still openings around the pipes under the dish machine, broken tiles, standing water, and many of the areas identified on the pest control reports were still present. The EVSD reported that he had caulked some holes in the kitchen walls, re-caulked around the base of the wall/floor, removed one wall on

the far side of the dish room and felt that he had corrected the issues identified in the pest control reports.

On 8/19/25 at 3:30 p.m., the surveyor and EVSD went to the ice machine on the second floor. It was observed that roaches were actively crawling along the floor in that room, water was standing in the floor, and gaps were noted in the wall around the pipes, which had been previously identified on the pest control reports as well. On 8/19/25 at 3:40 p.m., during an interview with the EVSD he was asked if he felt the current pest control program was effective. He reported that they had changed companies a few years ago because the prior company was not effective and he felt it was better than in the past. On 8/20/25 at 9:37 a.m., the surveyor used the bathroom located in the lobby and observed a roach crawling on the wall. On 8/20/25 at 9:45 a.m., during an interview with a licensed practical nurse (LPN #6), she was asked about pests. LPN #6 reported they do have a problem with roaches and said, It waxes and wanes, they come and spray. When asked if residents complaint about it, LPN #6 reported that residents complain about roaches frequently. On 8/20/25, during a clinical record review of a resident in the survey sample, it was noted that

in Resident #5's progress notes there was an entry dated 2/19/25, regarding an issue due to pests. The noted read, Maintenance spoke with SS [social services] and indicated that the resident had piles of books, magazines and newspapers that needed to be thrown away and also indicated that roaches was in his radio and that it needed to be discarded also. SS spoke with the resident and informed that he needed to discard the items including his radio. Resident acknowledged understanding and stated that he would be purchasing another radio. SS and nursing assistant discarded the resident's radio. SS notified UM that the radio had been discarded [sic]. On 8/20/25 at 4 p.m., during an end of day meeting with the facility administrator, director of nursing and regional director of operations, they were made aware of the above findings regarding pest control. On 8/21/25 at 8:55 a.m., when the surveyor was walking on the first-floor unit, a roach was noted crawling on the floor in the hallway. Review of the facility policy titled, Pest Control Policy was conducted. This policy read, Routine pest control procedures will be in place to prevent pest infiltration. If pests are seen in the kitchen, the director of food and nutrition services or designee shall be informed. Appropriate action will be taken to eliminate any reported pest situation in the department. No additional information was provided.

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Facility ID:

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