Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Monroe during CMS and state inspections, most recent first.
A resident with a history of chronic pain and recent fall continued to report significant pain, but the care plan was not updated and pain management remained PRN without scheduled medication or post-administration pain reassessment. Despite ongoing complaints and family concerns, the facility documented medications as effective and did not adjust interventions, leading to hospital transfer where multiple fractures were discovered.
A resident experienced disturbed sleep and back pain due to a mattress with a significant indentation. Despite reporting the issue weeks earlier, no action was taken until the resident expressed frustration to a surveyor. The facility's protocol required documentation in the TELS system, which was not done, and the staff failed to observe and document the mattress's condition during routine tasks.
Two residents with significant health conditions did not receive adequate nail care, resulting in unmet care needs. One resident with Multiple Sclerosis had long nails despite requiring extensive assistance, while another resident with Hemiplegia had untrimmed nails on one hand. Staff indicated that nail trims should occur on shower days, contributing to the oversight.
Failure to Properly Assess and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to properly assess and manage pain for a resident who experienced a fall with injury. The resident, who had a history of acute osteomyelitis, cerebral infarction, muscle weakness, lack of coordination, and chronic pain, suffered an unwitnessed fall and subsequently complained of pain in the left ribs, hip, and arm. Although initial assessments and x-rays did not reveal fractures or abnormal skin findings, the resident continued to report significant pain in the affected areas for several days following the incident. Despite ongoing complaints of pain, the resident's care plan was not updated or reviewed after the fall to reflect the new pain or to add interventions. Pain medications, including Tramadol and Percocet, were administered on an as-needed (PRN) basis, and pain scores were documented prior to administration. However, there was no documentation of pain scores after medication administration, and the facility did not implement scheduled pain medication to address the persistent pain. The documentation repeatedly noted the medications as "effective" without evidence of reassessment or adjustment to the pain management approach. Nursing notes indicated that the resident continued to exhibit signs of pain, such as yelling out and groaning, and required frequent repositioning and reassurance. Family members expressed concerns about the management of the resident's pain, and the resident was eventually transferred to the hospital at the family's request. Hospital evaluation revealed multiple fractures that had not been identified or addressed by the facility. The facility's actions did not align with its own pain management policy, which requires reassessment and care plan updates following changes in condition, such as after a fall.
Plan Of Correction
Element 1: Resident #901 no longer resides in the facility. Element 2: Current residents residing in the facility with pain are considered like residents. Current residents residing in the facility were assessed for pain on 4/3/25 by Director of Nursing/Designee. The Director of Nursing/Designee audited current residents with pain to ensure their pain was effectively managed on 4/3/25. Element 3: The Pain Management Policy was reviewed by the QAPI committee and deemed appropriate on 4/3/25. The Staff Development Coordinator/Designee educated licensed Nurses on the Pain Management Policy with emphasis on managing pain effectively when residents have a change in condition by 4/4/25 or prior to next scheduled shift. The DON/Designee will monitor residents to ensure that pain is being managed effectively for a change in condition during the clinical morning meeting. Physicians will be notified for Residents on PRN pain medications experiencing unresolved acute pain for effective pain management. Element 4: Director of Nursing/Designee will audit residents with pain to ensure pain management regimen is effective. Audits will be conducted weekly for 4 weeks and monthly thereafter until substantial compliance is achieved. Results of these Audits will be brought to the QAPI committee for review monthly. This audit will only be discontinued with substantial compliance and with the approval of the facility QAPI Committee. Administrator is responsible to maintain compliance. 4/4/25
Failure to Timely Provide New Mattress for Resident
Penalty
Summary
The facility failed to provide a new mattress in a timely manner for a resident, resulting in the resident experiencing disturbed sleep patterns and back pain. The resident, who was cognitively intact with a BIMS score of 15/15, reported the issue to a staff member approximately three weeks prior to the surveyor's observation but was unsure of the staff member's name. The resident's mattress was observed to have a significant indentation, which was causing discomfort and difficulty in sleeping. The resident's medical history included conditions such as a history of falling, generalized epilepsy, dementia, anxiety disorder, extrapyramidal and movement disorder, and osteoarthritis. The facility's protocol required staff to document requests for new mattresses in the TELS system, but no such order was placed until the resident expressed frustration to a surveyor. The assigned CNA confirmed that the staff should have documented the need for a new mattress, and the maintenance staff acknowledged the resident's request and the mattress's condition. The Director of Nursing confirmed that the staff should have observed and documented the mattress's condition during routine bed linen changes. The facility's policy on Accommodation of Needs emphasized treating residents with respect and dignity and making reasonable accommodations for their individual needs and preferences.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, resulting in unmet care needs. Resident R5, diagnosed with Multiple Sclerosis and other conditions, required extensive assistance with activities of daily living (ADLs) and was observed with long fingernails extending past the top of their fingers. Despite R5's dependency on staff for personal hygiene, their nails were not trimmed as promised during their shower or bed bath. R5 expressed frustration over the untrimmed nails, indicating that staff had repeatedly assured them that nail care would be provided during their shower times. Similarly, Resident R66, who required substantial assistance with personal hygiene due to conditions such as Cerebral Infarction and Hemiplegia, was observed with untrimmed nails on their right hand. Although the nails on the left hand were trimmed, the right hand's nails were long, and R66 expressed frustration over their inability to cut their own nails. Interviews with CNAs and the Director of Nursing revealed that nail trims were expected to occur on shower days unless residents specifically requested them, which contributed to the oversight in providing necessary nail care for these residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Rehabilitation And Nursing Center | 0.6 mi | ★★★★★ | 13 | 0 |
| Ihm Senior Living Community | 0.8 mi | ★★★★★ | 0 | 0 |
| Monroe Springs Skilled Nursing And Rehab | 1.1 mi | ★★★★★ | 8 | 0 |
| Wellspring Lutheran Nursing And Rehab Services | 1.6 mi | ★★★★★ | 18 | 0 |
| Fountain View Of Monroe | 1.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.