Below 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 Monroe Community Hospital during CMS and state inspections, most recent first.
A resident with a history of constipation and multiple comorbidities experienced an extended period without a documented bowel movement, despite having PRN laxative orders. Staff did not act on electronic alerts or bowel movement reports, and there was no evidence of PRN medication administration or provider notification. The resident was hospitalized with severe stool impaction and returned to the facility, where the same issues recurred. Staff interviews revealed inconsistent understanding and use of bowel management protocols, and the facility lacked a written protocol specifying monitoring and intervention parameters.
A resident with limited mobility and a history of multiple sclerosis returned from the hospital with a sacral wound, but staff failed to follow wound care instructions, did not consistently assess or document the wound, and did not notify the wound care team or provider in a timely manner. The wound deteriorated from Stage 1 to Stage 4, causing severe pain and infection, and ultimately required surgical debridement. Gaps in communication, documentation, and adherence to policy contributed to actual harm.
A resident with a history of pressure ulcers and high risk for skin breakdown was transferred to another unit without their ordered ROHO specialty mattress. Nursing staff failed to ensure the mattress was moved or alternative interventions were implemented, resulting in the development of new stage 2 and stage 3 pressure ulcers. Documentation and staff interviews confirmed the mattress was absent for several days, and the wounds were attributed to this lapse.
The facility failed to develop baseline care plans within 48 hours of admission for all residents reviewed. For some residents, there was no evidence of a care plan being developed, while for others, summaries of the care plans were not provided to residents or their representatives. Interviews with staff revealed inconsistencies in initiating and documenting care plans, with some plans lacking physician's orders. The DON acknowledged issues with the electronic care plan form, which did not confirm receipt by residents or representatives.
Two residents experienced delays in receiving care, with call lights repeatedly turned off without addressing their needs. One resident with quadriplegia and another with dementia were left unassisted for extended periods, highlighting issues with staff response and dignity in care.
A facility failed to notify the medical team of a significant change in a resident's condition, who had a tracheostomy and was dependent on care. Observations showed excessive secretions in the tracheostomy cannister and oxygen tubing, but there was no documentation of physician notification. Staff interviews confirmed the medical provider should have been informed, but this protocol was not followed, leading to the deficiency.
Failure to Implement Effective Bowel Management Protocol Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who had diagnoses including multiple sclerosis, depression, generalized weakness, hypothyroidism, and a history of constipation, did not have a documented bowel movement for an extended period. Despite having physician orders for as needed laxatives, there was no documented evidence that these medications were administered during the period of no bowel movements. The facility's electronic medical record system was programmed to generate alerts and reports for absent bowel movements, but there was no evidence that these alerts and reports were reviewed or acted upon by staff during the relevant timeframes. The resident was eventually hospitalized after developing fever and tachycardia, where imaging revealed a severe rectal stool burden and stercoral colitis, requiring manual disimpaction. Upon return from the hospital, the resident again had no documented bowel movement for several days, and as needed bowel medications were not administered until several days later. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of bowel management protocols, with some staff unaware of the resident's condition or the need to act on bowel movement alerts. The facility did not have a written bowel management protocol specifying monitoring timeframes or parameters for administering as needed medications, and staff relied on inconsistent practices for reviewing and acting on bowel movement reports. Documentation showed that the resident was repeatedly listed on bowel movement reports as having no bowel movement, but there was no evidence of follow-up or intervention. Staff interviews indicated confusion about the frequency and use of bowel movement reports and alerts, and some staff were not aware of the resident's prolonged constipation or the need to notify providers. The lack of a clear, written bowel management protocol and failure to act on documented alerts and reports resulted in actual harm to the resident, as well as a likelihood of serious harm for other residents.
Removal Plan
- The facility provided a copy of the defined Bowel Management Regimen policy and procedure.
- The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports.
- The facility provided supporting documentation for nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift.
- A list of all facility residents who did not have a documented bowel movement in three days was provided.
- Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns.
Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple sclerosis, depression, and generalized weakness, who was cognitively intact, experienced a significant lapse in pressure ulcer care following a hospital admission for stroke-like symptoms. Upon return to the facility, the resident had a sacral wound with specific wound care instructions from the hospital, but there was no documented evidence that new wound care orders were entered or that the wound was properly assessed and treated from the time of readmission through several weeks. Nursing documentation was inconsistent, with gaps in dressing changes, skin checks, and provider assessments. The wound was not seen by a provider or the wound care team for an extended period, despite staff being aware of the open area and pain reported by the resident. The facility's policy required comprehensive skin assessments, weekly skin checks, daily visual checks by CNAs, and prompt notification and documentation of new skin issues. However, these protocols were not followed. Staff failed to notify the wound care team or medical providers in a timely manner, and incident reports were not consistently initiated for new or worsening wounds. Communication among staff was fragmented, with some nurses and providers unaware of the resident's condition or missing documentation of assessments and interventions. The resident's wound deteriorated from a Stage 1 to a Stage 4 pressure injury, with increasing pain and signs of infection, ultimately requiring sharp debridement during a subsequent hospitalization. Interviews with staff revealed confusion about reporting requirements, inconsistent practices regarding skin checks and incident reporting, and missed opportunities for timely intervention. The resident reported prolonged periods in bed due to lack of assistance, contributing to the worsening of the wound. Observations confirmed that pain was not addressed during wound care. The cumulative failures in assessment, documentation, communication, and timely intervention resulted in actual harm to the resident and placed other residents with pressure ulcers at risk for serious harm.
Removal Plan
- All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness.
- The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment plan was initiated.
- Wound Care staff received re-education on the revised policy and procedure.
Failure to Provide Ordered Specialty Mattress Results in Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with a history of pressure ulcers and multiple risk factors, including diabetes and muscle weakness, was transferred to another unit without their prescribed specialty ROHO mattress. The resident had physician orders for the specialty mattress to be in place and checked every shift, as well as a care plan identifying them as high risk for pressure injuries. Despite these orders and the facility's policy requiring all specialty mattresses to be checked and maintained, the mattress was not transferred with the resident, and staff documented its absence on several shifts. During the period when the specialty mattress was not in place, the resident developed new pressure ulcers: a stage three full-thickness wound on the left buttock and a stage two partial-thickness wound on the right buttock. Multiple staff interviews and documentation confirmed that the mattress was not present for several days following the transfer, and that nursing staff were aware of the absence but did not ensure the mattress was moved or that alternative interventions were implemented. The facility's own investigation and wound care assessments attributed the development of these wounds to the lack of the specialty mattress during this time. Interviews with clinical staff, including the wound care nurse, physician assistant, and medical director, confirmed that the absence of the specialty mattress directly contributed to the resident's skin breakdown. The medical director specifically stated that the pressure ulcers were avoidable and that the resident's condition had been stable prior to the transfer. Documentation also showed inconsistencies in the treatment administration record, with some staff marking the mattress as 'administered' when it was not present, further indicating lapses in care and documentation.
Failure to Develop and Communicate Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were developed within 48 hours of admission for all 11 residents reviewed during the recertification survey. Specifically, for three residents, there was no documented evidence that a baseline care plan was developed within the required timeframe. For one resident, the baseline care plan was completed after the 48-hour window, and there was no evidence that a summary of the care plan, including physician's orders, was provided to the resident's representative. Additionally, for seven residents, the facility could not provide evidence that a summary of the baseline care plan, including necessary healthcare information, was provided to the residents or their representatives. Interviews with facility staff revealed that the baseline care plans were not consistently initiated or documented as required. One nurse manager acknowledged that the baseline care plan should have been initiated upon admission, while another stated that the care plan focused primarily on nursing care and did not include physician's orders. The Director of Nursing admitted awareness of the issue with the electronic baseline care plan form, which implied but did not confirm the review or receipt of the care plan by residents or their representatives. This lack of documentation and communication led to the deficiency identified in the survey.
Deficiencies in Resident Dignity and Timely Assistance
Penalty
Summary
During a recertification survey and complaint investigation, deficiencies were identified in the treatment of two residents regarding their dignity and the timely response to their needs. Resident #640, who has quadriplegia, neurogenic bladder, and diabetes, was observed to have their call light repeatedly turned off by staff without addressing their requests for assistance. Despite being cognitively intact, Resident #640 expressed frustration and discomfort due to being left unwashed for an extended period, with a foul odor present in the room. The resident's requests for help were not promptly addressed, and it took approximately two hours before they received the necessary care. Similarly, Resident #27, who has dementia, diabetes, and high blood pressure, was observed moaning with their call light on, yet staff did not promptly respond to their needs. The resident's call light was turned off without providing assistance, and it took nearly 50 minutes before they received care. Interviews with staff revealed issues with staffing shortages and a lack of timely response to call lights, contributing to the delay in addressing the residents' needs. The facility's staff, including CNAs and the unit administrator, acknowledged the responsibility to answer call lights and meet residents' needs. However, the survey highlighted a failure to ensure that residents were treated with dignity and received timely assistance, as evidenced by the prolonged periods before the residents' needs were addressed. The Director of Nursing emphasized the importance of responding to call lights and providing care when requested, but the observations indicated a gap in practice.
Failure to Notify Medical Team of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the medical team of a significant change in condition for Resident #186, who had a tracheostomy and was dependent on care for all activities of daily living. The resident had a history of anoxic brain damage, dysphagia, and was on aspiration precautions. Observations during the survey revealed that the resident's tracheostomy cannister contained more than 450 milliliters of tan-colored secretions, and thick tan/yellow secretions were noted in the oxygen tubing attached to the tracheostomy. Despite these observations, there was no documentation that the physician was notified of the excessive secretions or the potential aspiration risk. Interviews with staff, including LPNs and the Respiratory Therapy Manager, confirmed that the medical provider should have been notified of any significant changes, such as excessive sputum or potential aspiration. However, the physician was not informed about the possibility of tube feeding liquid in the tracheostomy tubing, which was considered a serious complication. The facility's policy required immediate consultation with the resident's physician in the event of a significant change in physical status, but this protocol was not followed, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 145 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodside Manor Nursing Home Inc | 0.9 mi | ★★★★★ | 7 | 0 |
| The Hurlbut | 1.1 mi | ★★★★★ | 0 | 0 |
| The Highlands At Brighton | 1.2 mi | ★★★★★ | 12 | 0 |
| St. John's Health Care Corporation | 1.2 mi | ★★★★★ | 0 | 0 |
| The Brightonian, Inc | 1.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monroe Community Hospital.
100% money-back within 48 hours.
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.