Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Monroe Springs Skilled Nursing And Rehab during CMS and state inspections, most recent first.
A resident who was totally dependent for transfers and required a mechanical lift with two staff was transferred by only one CNA. During the transfer, the sling slipped off a hook and the resident fell headfirst to the floor, sustaining a head laceration that required five staples after hospital evaluation.
Failure to notify the physician of missed medication doses: A resident admitted with COPD missed two consecutive doses of Advair Diskus and Cefadroxil after the inhaler was documented as unavailable, and the MAR showed both medications were not administered for two scheduled doses. There was no documentation that the physician was notified, and the DON acknowledged the missed doses and lack of notification despite facility policy requiring notification when two doses are refused or withheld.
Failure to report an injury of unknown origin: A resident with MS, severe malnutrition, dementia, impaired cognition, and total dependence for bed mobility and transfers developed a proximal femur fracture after reporting pain. The NHA stated the facility could not determine how the fracture occurred, the resident denied abuse, and the injury was not reported to the State Agency because staff did not believe it was abuse or an allegation of abuse.
Failure to Schedule Ordered Cataract Extraction: A resident with legal blindness and other diagnoses was ordered for bilateral cataract extraction, but the facility did not make the ophthalmology appointment or document that it was rescheduled. The resident reported repeated unanswered questions about why the cataracts had not been removed, while the SW said the facility could not contact the family for transport and did not follow through on rescheduling. The DON and NHA confirmed the appointment had not been made.
Improper labeling and storage of resident food in unit refrigerators. Unit refrigerators contained expired fruit, bread, cake, spinach dip, and leftover meal items that were unlabeled and/or undated. The DS stated dietary staff were responsible for maintaining the refrigerators and that resident food items needed to be labeled and dated, and the DON confirmed the expectation that resident food be labeled and dated and expired food discarded. Facility policy required perishable foods to be stored in resealable containers with the resident's name, item, and use-by date.
A resident with stroke and dysphagia had a compromised PEG tube that was missing its cap and not securely connected, with tape covering the opening and beige tube feeding residue present. During med pass, an LPN observed crushed meds inside the tube, difficulty administering meds and flushes, and leakage back out of the PEG. The resident’s chart included orders for PEG site care and notification of the medical provider if placement concerns arose, but recent progress notes did not document the tube issue.
Misappropriation of Resident Narcotic Medication: A resident’s oxycodone tablets were missing and unaccounted for during an AM narcotic count after the discrepancy began with an RN. The resident had intact cognition, was their own responsible party, and reported receiving pain meds as requested, but 26 tablets of the resident’s narcotic pain medication could not be accounted for.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate supervision during a mechanical lift transfer for a resident who was totally dependent on staff for bed mobility and transfers. The resident had diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia, and the care plan and Kardex indicated the resident required a mechanical lift and two staff persons for transfers. During the transfer, only one CNA assisted, and the sling slipped off one of the hooks, causing the resident to slide off the sling and fall headfirst to the floor, striking the head. After the fall, the resident was noted to have a small laceration on the top of the head and was sent to the hospital for evaluation. The resident returned later the same day with five staples to close the head wound. The post-fall assessment documented that the resident fell from the lift during transfer with only one staff member present, and the CNA acknowledged performing the transfer alone despite knowing two staff were required.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify the physician of missing medications for one resident, R506, after two consecutive doses were not administered for Advair Diskus, a respiratory inhaler ordered every 12 hours for COPD, and Cefadroxil, an antibiotic ordered twice daily. R506 was admitted to the facility on [DATE], and the admission orders dated 4/8/26 included both medications. A progress note on 4/8/26 at 6:40 PM stated that R506's Advair Diskus was not available. Review of the April 2026 MAR showed that both Advair Diskus and Cefadroxil were not given at the 9:00 PM dose on 4/8/26 or the 9:00 AM dose on 4/9/26. There was no additional documentation showing that the physician was notified. During interview, the LPN stated that the doctor is supposed to be notified if two consecutive doses are missed, and the DON acknowledged that the two consecutive doses of both medications were not administered and that there was no documentation that the physician was notified. The facility policy stated that when two doses of a medication are refused or withheld, the DON and attending physician must be notified.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident reviewed for abuse. The resident had multiple sclerosis, severe malnutrition, and dementia, and the MDS indicated moderately impaired cognition with total dependence on staff for bed mobility and transfers. A progress note documented left knee pain, after which the physician was notified, pain medication was given, and an x-ray was ordered. The radiology report identified a slight comminuted fracture of the proximal left femur, and the resident was transported to the emergency room for further evaluation and treatment. During interview, the NHA stated the resident had a fall from a mechanical lift weeks earlier, but the resident did not complain of leg pain until much later and the facility did not think the fracture was caused by the fall. The NHA said the facility conducted an investigation and could not determine exactly when or how the fracture occurred, and the resident denied that staff had hurt them or been abusive. The NHA acknowledged the injury of unknown origin was not reported to the State Agency because it was not believed to be abuse and there was no allegation of abuse. The facility policy required investigation of injuries of unknown source and immediate reporting of allegations or suspicions of abuse/neglect, including preliminary reporting to the appropriate State Agency.
Failure to Schedule Ordered Cataract Extraction
Penalty
Summary
The facility failed to make an ophthalmology appointment as ordered for one resident, R505, who was reviewed for coordination of outside physician appointments. R505 was observed lying in bed with the TV on and reported that the facility had not scheduled the cataract extraction, stating that the doctor said vision would improve after cataract removal, that the resident had been set up to go but never returned to the eye doctor, and that repeated questions to staff had not produced an answer about why the cataracts had not been removed. Record review showed R505 was re-admitted with diagnoses including peripheral vascular disease and legal blindness. An Optometry Order Form dated 12/9/25 documented that the patient had been scheduled at a named eye center for bilateral cataract extraction and should be rescheduled when possible, but there was no further documentation showing the appointment was made. The SW stated the facility tried to set up an appointment but could not contact the family to assist with transport and did not know what happened afterward, and acknowledged the appointment should have been rescheduled. The DON and NHA both confirmed the cataract extraction appointment had not been made and could not explain why it was not done.
Improper Labeling and Storage of Resident Food in Unit Refrigerators
Penalty
Summary
The facility failed to properly date-label stored food and remove expired food from resident refrigerators. During observation with the Dietary Supervisor, the 2nd floor unit refrigerator contained expired fruit that was unlabeled, an unlabeled chocolate cake, and a half loaf of expired bread. The 3rd floor unit refrigerator contained a container of spinach dip that was unlabeled and undated, an expired cake that was unlabeled, and a container of leftover meal that was undated and unlabeled. The Dietary Supervisor stated dietary staff were responsible for maintaining the unit refrigerators and that resident food items needed to be labeled and dated. The DON stated the expectation was for resident food to be labeled and dated and for expired food to be thrown out. The facility policy required perishable foods to be stored in resealable containers, labeled with the resident's name, item, and use-by date, and required nursing staff to discard perishable foods on or before the use-by date.
Compromised PEG Tube With Poor Medication Administration
Penalty
Summary
Appropriate PEG tube care was not provided for a resident with a history of stroke and dysphagia who was admitted with a PEG tube for food, fluids, and medication administration. During observation of medication administration, the resident’s PEG tube was found compromised and missing its attached cap. The tube was clamped with a plastic clamp but was not securely capped, and the opening was covered with white tape that was soaked with beige liquid consistent with tube feeding formula. The tape slid off easily when touched, and the PEG tube was visibly worn with crushed medications observed inside the tube. Closer inspection showed the PEG tube port could not be securely connected to the feeding tube, and the connector port also had white tape covered with beige liquid. An LPN stated the cap was broken off, the connection was not secure, and the tube needed to be replaced. The LPN attempted to use a new connector from central supply, but it still did not fit securely. Medication and water flush administration was very slow, took several minutes, and some of the flush leaked back out of the PEG tube. The resident’s record included an order to cleanse the PEG site and notify the medical provider if there were concerns with placement, and the care plan directed staff to provide ordered tube site care and monitor for signs and symptoms of infection. Progress notes from the prior month did not document concerns about the PEG tube, although the DON stated the tube had been noted as compromised earlier and there was no progress note or documentation in the chart.
Misappropriation of Resident Narcotic Medication
Penalty
Summary
The facility failed to protect a resident’s property from misappropriation when 26 tablets of R22’s narcotic pain medication, oxycodone 10-325 mg, were missing and could not be accounted for during an A.M. shift change narcotic count. The facility’s investigation determined the discrepancy began with RN E on 3/10/25, and the missing medication was identified in the facility-reported incident received by the State Agency on 3/11/25. R22 was admitted with diagnoses including a history of cellulitis and a left leg above-the-knee amputation, had intact cognition, and was their own responsible party. The resident reported receiving pain medication as requested and stated they knew the medications were missing only after being told by staff. The resident had no concerns at the time of interview, and the MAR showed medications were being administered as prescribed.
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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) |
|---|---|---|---|---|
| Fountain View Of Monroe | 0.6 mi | ★★★★★ | 4 | 0 |
| Seacrest Rehabilitation And Nursing Center | 0.6 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Monroe | 1.1 mi | ★★★★★ | 0 | 0 |
| Ihm Senior Living Community | 1.2 mi | ★★★★★ | 0 | 0 |
| Wellspring Lutheran Nursing And Rehab Services | 2.2 mi | ★★★★★ | 18 | 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.