Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Rest Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with nicotine dependence was found vaping in a non-smoking area and had a vaping pen in her possession, despite facility policy prohibiting smoking materials in resident rooms and requiring quarterly safe smoking assessments. The facility failed to complete these assessments due to a system changeover, resulting in the resident being able to keep vaping materials in her room without staff knowledge.
A Physician Assistant and an agency nurse failed to follow infection control policies by not donning gowns and gloves before entering a resident's room on enhanced barrier precautions and by not performing hand hygiene or changing gloves between wound care steps. The nurse used multiple layers of gloves instead of changing them as required, and both staff members did not adhere to the facility's Enhanced Barrier Precautions policy during wound care.
A resident's debit card was used without authorization during their hospitalization, resulting in multiple transactions at a vending machine and a pizza delivery. The facility's investigation, including camera footage review and interviews, failed to identify the responsible party. The police were involved but could not prove theft. The bank reimbursed the charges, and the guardian chose not to press charges against the resident's roommate.
A resident with a Stage 4 pressure ulcer did not receive a scheduled dressing change due to a communication lapse when the Wound Care Nurse left early. The agency nurse assigned was not informed of the responsibility, resulting in the missed care. The resident's wound was improving, and the missed change did not negatively affect the wound, as confirmed by the Wound Care Physician Assistant and Physician.
Failure to Perform Quarterly Safe Smoking Assessments and Secure Smoking Materials
Penalty
Summary
The facility failed to perform required quarterly safe smoking assessments and did not secure smoking materials, specifically a vaping pen, for one resident. According to the facility's smoking policy, residents are not permitted to keep smoking-related materials, including electronic smoking devices, on their person or in their rooms when not smoking. The policy also requires quarterly evaluations by the interdisciplinary team to assess residents' ability to smoke safely. However, the facility missed quarterly safe smoking assessments for some residents, including the resident involved in this incident, due to a system changeover that cleared assessment schedules. A resident with a history of type 2 diabetes, cerebral infarction without residual deficits, and nicotine dependence was assessed as a safe smoker and allowed to smoke or vape independently. The resident was observed vaping in the doorway of her room, which is a non-smoking area, and admitted to keeping a vaping pen on her person. She stated she was aware of the policy prohibiting smoking or vaping in her room and acknowledged that the facility was unaware she had the vaping pen in her possession. The resident also had access to a locker in the courtyard for storing smoking supplies but kept the key and vaping pen with her in her room, contrary to facility policy. Staff interviews confirmed that the resident had not been observed smoking or vaping inside the facility prior to this incident. The facility's unit manager and administrator were unaware that the resident had vaping materials in her room until informed by the surveyor. The administrator later confirmed that quarterly safe smoking assessments were missing for some residents, including the one involved, due to an electronic charting system issue during a company transition.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to follow its infection prevention and control policies during wound care for a resident on enhanced barrier precautions. Specifically, a Physician Assistant and an agency nurse did not don gowns and gloves before entering the resident's room, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The nurse donned multiple layers of gloves at the wound care cart, used hand sanitizer, and entered the room without a gown. The Physician Assistant washed his hands and donned gloves at the bedside but also did not wear a gown. During the wound care procedure, the nurse removed and replaced dressings and bandages on both of the resident's feet and legs, but failed to change gloves or perform hand hygiene between steps, instead relying on removing outer layers of gloves. Hand hygiene was not performed between glove changes or between care of different wounds, contrary to facility policy. Interviews with staff revealed that the Physician Assistant was unaware the resident was still on enhanced barrier precautions, and the agency nurse misunderstood the facility's glove use policy, believing multiple layers of gloves were acceptable. The Unit Manager and Director of Nursing confirmed that the correct procedure was not followed, and that signage and supplies for EBP were present on the resident's door. The nurse involved had completed the facility's infection control and handwashing training prior to the incident.
Unauthorized Use of Resident's Debit Card During Hospitalization
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when the resident's debit card was used without authorization during his hospitalization. The resident, who was severely cognitively impaired, was admitted with diagnoses including lung disease and heart failure. While the resident was hospitalized, his debit card was used for multiple transactions, primarily at a vending machine, and for a pizza delivery. The resident's guardian discovered the unauthorized transactions after the resident's death and reported the issue to the facility. The facility conducted an investigation, including reviewing camera footage and interviewing staff and residents, but was unable to identify the individual responsible for the unauthorized use of the debit card. The police were also involved but could not determine if the debit card was stolen. The facility did not reimburse the guardian for the charges, stating it was the bank's responsibility. The bank eventually reimbursed the charges, and the guardian chose not to press charges against the resident's roommate, who denied any involvement.
Missed Pressure Ulcer Dressing Change
Penalty
Summary
The facility failed to change a pressure ulcer dressing according to physician orders for a resident with a Stage 4 pressure ulcer. The resident was admitted with diagnoses including a pressure ulcer and hypertension and was severely cognitively impaired. The wound care orders specified daily dressing changes, but on one occasion, the dressing was not changed as required. The Treatment Administration Record lacked documentation of the dressing change, and an observation confirmed the dressing had not been changed on the specified date. The Wound Care Nurse left work early on the day the dressing change was missed, and the responsibility was not communicated to the nurse assigned to the hall. The Unit Manager and Director of Nursing were aware of the Wound Care Nurse's early departure, but the agency nurse assigned to the resident was not informed of the need to complete the wound care. Interviews with the Wound Care Physician Assistant and the Physician indicated that the missed dressing change did not negatively affect the resident's wound, which was improving. The Director of Nursing and the Administrator acknowledged the oversight and emphasized the expectation for wound care to be completed according to physician orders.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jesse Helms Nursing Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Monroe Rehabilitation Center | 2 mi | ★★★★★ | 4 | 0 |
| Pruitthealth-union Pointe | 4.6 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Marshville | 7 mi | ★★★★★ | 5 | 0 |
| Lake Park Nursing And Rehabilitation Center | 10.6 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.