Average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monarch Meadows Nursing And Rehabilitation during CMS and state inspections, most recent first.
Kitchen sanitation, food labeling, and hand hygiene failures. The kitchen had uncovered trash in the handwashing area, unlabeled and undated food items in the refrigerator, grease and food debris on multiple surfaces and equipment, and debris on ceiling detectors above clean utensil storage. Dishwasher rinse temperatures were repeatedly recorded below the required 180°F, and a DA was observed handling a blender and touching soiled surfaces while preparing puree and mechanical soft foods without washing hands, which the DM verified should have been done to prevent cross contamination.
A resident with a physician's order for DNR-Comfort Care Arrest did not have signed DNR paperwork in the medical record. When the resident became unresponsive and pulseless, staff initiated CPR because the required documentation was missing, despite the DNR order. The DON confirmed the facility had not ensured the presence of signed DNR paperwork, leading to resuscitation efforts contrary to the resident's code status.
Delayed Physician Notification After Resident Fall and Pain Complaints: A resident with respiratory failure, a hx of falls, difficulty walking, osteoporosis, and lack of coordination had a witnessed fall with c/o right thigh pain, followed by right shoulder pain. Former LPNs documented monitoring and education about an x-ray, but there was no documentation that the MD was notified until later that evening, when an LPN obtained stat x-ray orders for the shoulder and hip. The DON verified the lack of timely notification, and the facility policy required notification within 24 hours of a change in condition.
A resident with schizoaffective disorder, dementia, and anxiety had an inaccurate MDS. MAR/TAR review showed daily Olanzapine use and a Wanderguard, but the quarterly MDS stated the resident did not receive antipsychotics and did not use a wander/elopement alarm. An RCN confirmed the MDS should have reflected both findings.
Failure to Update PASARR After New Serious Mental Diagnoses: The facility did not complete accurate PASARR reviews after three residents had significant changes in serious mental diagnosis. One resident developed schizoaffective disorder, another received a new diagnosis of unspecified psychosis, and a third received a new diagnosis of delusions, but the PASARRs on file did not reflect those diagnoses. The SSD verified that updated PASARRs were required within 14 days after the new diagnoses, and the facility policy required PAS/RR completion after a significant change in condition.
Missing Care Plans for Dementia and Weight Loss Risk: Two residents lacked required care plans. One resident had severe dementia with severely impaired cognition, but no dementia care plan was in place. Another resident had a history of severe weight loss and was identified as at risk for further weight loss, but no nutrition care plan was developed. The DON verified both omissions.
The facility failed to provide timely care after a resident’s fall and pain complaints when the physician was not notified right away and a stat x-ray was delayed until the next day, revealing a shoulder dislocation. The facility also failed to obtain ordered weights for two residents with heart failure, with multiple scheduled weights not completed or refused and confirmed missing by a regional clinical nurse.
Failure to assess and treat a resident's sacral pressure ulcer occurred when a healing stage 1 area with non-blanchable redness was documented, but no description, measurements, treatment orders, or follow-up assessments were found in the record. The resident had DM, protein-calorie malnutrition, and impaired cognition, and the DON confirmed the facility was unaware of the pressure area and had not completed further assessment or treatment.
A resident with repeated falls and impaired cognition was found on the floor twice, once with minor injuries and later on a mat beside the bed. The care plan listed fall precautions such as bed stabilizers, a locked bed, clear pathways, and non-skid strips, but the mat intervention identified after the later fall was not included in the care plan at the time of the incident.
Failure to assess and plan for trauma-informed care. A resident with dementia and intact cognition had a known history of spousal abuse, and the spouse was removed from the building after being abusive to her. The medical record and care plan did not include a PTSD assessment or any trauma-informed care documentation. The DON confirmed there were no trauma or PTSD assessments, and the resident reported a past abusive marriage, prior self-harm, and psychiatric evaluation related to the abuse.
A resident with DM and impaired cognition had a physician visit note stating that 10 units of Lantus were to be given at bedtime for elevated blood sugars, but the order was not transcribed into the chart or implemented. Review of the MAR showed the bedtime Lantus was not administered, and the DON confirmed the order had not been entered because the facility did not realize it needed to write orders from the physician's visit note.
Delayed Stat X-Ray Services: A resident with a history of falls, neuropathy, osteoporosis, and lack of coordination had a stat order for a right shoulder x-ray after injury, but the x-ray was not obtained and read until the next morning. The DON and an LPN verified the delay, and the facility’s portable x-ray contract required stat response within 2.5 hours or less.
Kitchen sanitation, food labeling, and hand hygiene failures
Penalty
Summary
The facility failed to store and prepare food and maintain the kitchen in a sanitary manner. During observation of the kitchen, the handwashing area had an uncovered garbage container filled with used towels. In the walk-in refrigerator, there was an unsealed bowl of cottage cheese with no label and no date, a container of chopped ham with no label and dated 09/11/25, a container of cottage cheese dated 09/11/25, and five plates of salads with no label and no date. The food preparation equipment area had a large buildup of grease around the deep fryer with grease drips down the sides, food debris drips on the microwave table, dark brown debris on the wall adjacent to the floor cove base, dried food drips on the front of the food stream table, dried brown food debris on the front of the convection oven, and brown food debris collected on three fire ceiling detectors above clean utensil storage. The dishwasher temperature log listed the required rinse temperature as 180 degrees Fahrenheit, but on multiple dates the recorded rinse temperature was 150 degrees Fahrenheit, and Dietary Aide #119 had recorded those temperatures. The Dietary Manager verified that foods should be labeled and dated and discarded within three days of use, that the food preparation equipment and area should be clean and sanitary, and that the dishwasher temperatures during the Dietary Aide's days of work were incorrect because she had read the final rinse temperatures incorrectly. During a later observation, [NAME] #117 prepared puree food in a blender, sanitized the blender bowl and blade in the dishwasher, then continued touching the dishwasher, soiled counter, and soiled carts without washing hands before removing and reassembling the blender parts and processing mechanical soft chicken. [NAME] #117 again returned the soiled parts to the dishwasher and continued touching soiled surfaces without washing hands, and the Dietary Manager verified she should have sanitized her hands when reassembling the food processor to prevent cross contamination.
Failure to Maintain Signed DNR Documentation Resulted in Unwanted CPR
Penalty
Summary
The facility failed to ensure that signed Do Not Resuscitate (DNR) paperwork was present in the medical record for a resident who had a physician's order for DNR-Comfort Care Arrest (DNRCCA) code status. Record review showed that although the resident had a documented DNR order, there was no corresponding signed DNR paperwork in the chart. When the resident became unresponsive and was found without a pulse, staff initiated cardiopulmonary resuscitation (CPR), including chest compressions and bagging, until EMS arrived. The nursing progress note confirmed that CPR was performed because the required DNR documentation was not available in the medical record. Staff interviews confirmed that CPR was initiated due to the absence of signed DNR paperwork, despite the presence of a physician's order for DNR status. The Director of Nursing acknowledged that the facility had not ensured the necessary DNR documentation was present to prevent resuscitation efforts. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for advance directives.
Delayed Physician Notification After Resident Fall and Pain Complaints
Penalty
Summary
The facility failed to ensure the physician was notified timely of a resident’s change in condition after Resident #5, who had diagnoses including respiratory failure, history of falling, difficulty walking, osteoporosis, and lack of coordination, experienced a witnessed fall on 05/23/25 at 5:59 A.M. The resident reported pain in the right thigh, and Former LPN #200 documented to monitor the area, but there was no documentation that the physician was notified of the fall or the thigh pain. The resident then began complaining of right shoulder pain at 6:07 A.M., and Former LPN #300 documented that the resident was educated on possibly getting an x-ray, but again there was no notification to the physician regarding the shoulder pain. Review of the physician orders showed that a stat right shoulder x-ray was not ordered until 10:44 P.M. on 05/23/25. The DON verified that Former LPN #200 did not document physician notification in the nursing progress notes regarding the fall and thigh pain, and that there was no documentation the physician had been notified of the resident’s change in condition until LPN #150’s documentation at 10:44 P.M. Interview with LPN #150 indicated she notified the physician and obtained a stat x-ray order for the right shoulder and right hip at approximately 8:00 P.M., and charted the order in the medical record at 10:00 P.M. The facility policy titled Status Change in Resident Condition stated notifications would be made within twenty-four hours of a change in the resident’s condition or status.
Inaccurate MDS Coding for Antipsychotic Use and Wander Alarm
Penalty
Summary
The facility failed to ensure MDS assessments were coded accurately for one resident reviewed. Resident #4 was admitted with diagnoses including schizoaffective disorder, ventricular dementia, and anxiety disorder. Review of the 07/2025 MAR and TAR showed the resident received Olanzapine, an antipsychotic medication, and used a Wanderguard every day of the month. However, the quarterly MDS assessment dated 07/21/25 stated that the resident did not receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment and did not use a wander/elopement alarm during the seven-day lookback period. During interview, the Regional Clinical Nurse confirmed the MDS assessment was inaccurate and stated it should have reflected that the resident received antipsychotics and had a wander/elopement alarm.
Failure to Update PASARR After New Serious Mental Diagnoses
Penalty
Summary
The facility failed to ensure PASARR reviews were completed accurately after residents experienced significant changes in serious mental diagnosis. Record review, staff interview, and policy review showed that three residents reviewed for PASARR had new or changed psychiatric diagnoses, but the facility did not provide updated PASARR documentation reflecting those changes. The facility census was 47. Resident #9 was admitted with schizoaffective disorder and anxiety disorder, had impaired cognition on MDS, and later received a new diagnosis of schizoaffective disorder. Resident #2 was admitted with psychosis, had moderately impaired cognition, and later received a new diagnosis of unspecified psychosis. Resident #13 was admitted with delusional disorders and anxiety disorder, had intact cognition, and later received a new diagnosis of delusions. For each resident, the PASARR on file did not include the new serious mental diagnosis, and Social Services Director #162 verified that a significant change PASARR was required within 14 days after the new diagnosis. The facility policy stated that the admission director or designee would complete PAS/RR when a resident experienced a significant change in condition and that residents with newly diagnosed or possible serious mental disorder would be referred to the Ohio Department of Aging upon significant change in status.
Missing Care Plans for Dementia and Weight Loss Risk
Penalty
Summary
The facility failed to ensure care plans were in place for dementia care and for a history of severe weight loss for two residents reviewed for care planning. Resident #3 was admitted with diagnoses including dementia, disorientation, and delirium; the MDS dated 08/26/25 showed severely impaired cognition, and the physician orders and diagnosis list reflected a recent diagnosis of severe dementia on 08/14/25. Review of Resident #3's care plan showed no dementia care plan had been created, and the DON verified this on 09/17/25. Resident #7 was admitted with diagnoses including dysphagia, anemia, chronic kidney disease, and constipation; the MDS dated 08/26/25 showed intact cognition, and the physician orders and nutritional assessments identified the resident as at risk for further weight loss due to a prior severe weight loss. Review of Resident #7's care plan showed no nutrition care plan had been created, and the DON verified this on 09/17/25.
Delayed response to change in condition and missed ordered weights
Penalty
Summary
The facility failed to ensure timely care and services during a change in condition for Resident #5 after a witnessed fall. The resident, who had diagnoses including a history of falling, neuropathy, osteoporosis, and lack of coordination, reported right thigh pain after the fall and later complained of right shoulder pain. Nursing documentation showed the physician was not notified of the fall, the thigh pain, or the shoulder pain at the time they occurred, and there was no follow-up in the medical record until later that evening when a stat right shoulder x-ray was ordered. The portable x-ray contract stated stat x-rays were to have a response time of two and a half hours or less, but the x-ray was not obtained and read until the next day, when results showed a right shoulder dislocation and the resident was sent to the hospital for evaluation. The facility also failed to obtain weights as ordered for Resident #1 and Resident #23. Resident #1 had diagnoses including heart failure and encephalopathy, and the physician ordered weights every Monday, Wednesday, and Friday with notification for a gain of five or more pounds in one week. Review of the TAR and weight records showed multiple ordered weights were not obtained or were refused over the review period. Resident #23, who had diagnoses including heart failure and hypertension, also had a physician order for weights every Monday, Wednesday, and Friday with the same notification parameter, and the record showed several ordered weights were not obtained or were refused. A regional clinical nurse confirmed that the weights had not been obtained as ordered for both residents.
Failure to Assess and Treat a Resident's Sacral Pressure Ulcer
Penalty
Summary
Failure to provide timely assessment and treatment for pressure ulcers occurred for one resident (#34) who was admitted with diagnoses including diabetes mellitus and protein-calorie malnutrition. The quarterly MDS dated 09/12/25 identified impaired cognition and risk for pressure ulcer development, but no pressure ulcers were present at that time. The care plan dated 06/06/25 identified the resident as at risk for impaired skin integrity/pressure ulcers and included interventions for skin assessment, daily skin inspection during care, and treatments per order. The admission packet evaluation dated 09/02/25 documented a healing stage one pressure ulcer with non-blanchable redness to the sacrum, but no description or measurements were recorded. There were no treatment orders for the sacral pressure area on 09/02/25, and no further assessments, treatment orders, or documentation of the sacral area were found in the resident's medical record. The DON confirmed on 09/17/25 that the facility was not aware the resident had been assessed with a pressure ulcer on 09/02/25 and verified that no treatment orders or further assessments had been completed. Observation on 09/17/25 showed no current pressure areas on the sacrum or buttocks.
Fall interventions not updated after resident falls
Penalty
Summary
The facility failed to ensure appropriate fall interventions were in place for a resident with a history of repeated falls and impaired cognition, and failed to update the care plan after a fall. Resident #34 was admitted with diagnoses including repeated falls, diabetes mellitus, and protein-calorie malnutrition. The quarterly MDS dated 09/12/25 documented impaired cognition, and the care plan identified the resident as at risk for falls and potential injury. The care plan listed interventions such as bed stabilizers, locking the bed, maintaining a clear pathway, monitoring for psychotropic side effects, non-skid strips, rest periods, and having the room close to the nurse’s station, but the dates those interventions were implemented were not provided. On 05/01/25, the resident was found on the floor next to the bed with an abrasion to the right shoulder and ear and discoloration to the right side of the face; the resident could not recall what happened due to baseline cognitive decline. The fall investigation stated the current fall prevention plan included bed stabilizers/lock bed, common items close, clear pathway, monitoring for psychotropic side effects, and room close to the nurse’s station, and identified non-skid strips to the right side of the bed as the new intervention to be added to the plan of care and CNA assignment sheet. On 05/19/25, the resident was again found on the floor, this time on a mat beside the bed, and could not describe what he was trying to do. The fall investigation for that event listed a non-skid floor mat at bedside, low bed, bed stabilizers/lock bed, and room close to the nurse’s station as the current prevention plan, but did not document the cause of the fall; the new intervention was to add a mat to the right side of the bed. RN interview confirmed the resident had been known to climb out of bed, that the care plan at the time of the fall did not include a mat, and that the care plan initiated on 03/21/25 and cancelled on 06/05/25 did not contain the mat intervention.
Failure to Assess and Plan for Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a resident was assessed and received trauma informed care related to a history of spousal abuse. Resident #42 was admitted with a diagnosis of dementia, and the state optional MDS assessment dated 08/04/25 indicated intact cognition. Review of the medical record found no indication that Resident #42 was assessed for PTSD, despite a known history of spousal abuse that led to the husband being removed from the facility after the resident’s admission. The resident’s medical record and plan of care did not address trauma informed care or a PTSD assessment. The DON verified that the spouse had been removed from the building because he was abusive to the resident and confirmed there had been no assessments or plan of care for trauma or PTSD. The resident stated she had an abusive marriage, had previously cut her wrists and been placed in a psychiatric facility for assessment, and was removed from her home for safety before being placed in the facility; she stated she felt safe there now and was not aware of any trauma informed care or PTSD assessment.
Failure to Transcribe and Implement Insulin Order
Penalty
Summary
Resident #34, who was admitted with diabetes mellitus and had impaired cognition on the quarterly MDS, was found to have a medication administration issue involving Lantus. The physician's visit note documented that the resident had diabetes mellitus with blood sugars often elevated and that the physician was going to order 10 units of Lantus at bedtime. Although the visit note was signed by the physician, review of the physician's orders showed that no order for 10 units of Lantus at bedtime had been initiated. Review of the MAR from 09/05/25 to 09/16/25 showed that the 10-unit bedtime dose of Lantus was not administered. The DON confirmed that the physician had ordered the Lantus on 09/05/25, but the order had not been transcribed or implemented by the facility, and stated the facility had an issue with receiving physician visit notes timely and did not realize orders were not being written from those notes.
Delayed Stat X-Ray Services
Penalty
Summary
The facility failed to obtain stat x-rays in a timely manner for Resident #5, who had diagnoses including history of falling, neuropathy, osteoporosis, and lack of coordination. A physician order dated 05/23/25 at 10:44 P.M. directed a stat right shoulder x-ray, and the resident’s record later showed x-ray results dated 05/24/25 at 10:48 A.M. with negative findings for the right hip and a right shoulder dislocation. Nursing documentation stated that the x-ray was completed in the morning and showed a dislocation of the right shoulder, after which the physician ordered the resident to the hospital for evaluation. During interviews, the DON verified that the stat x-ray was ordered on 05/23/25 at 10:00 P.M. and was not obtained and read by the physician until 05/24/25 at 10:49 A.M. The DON stated stat x-rays should have been obtained within four hours of the physician order. An LPN verified she notified the physician and obtained stat x-ray orders for the right shoulder and right hip at approximately 8:00 P.M., charted the order at 10:00 P.M., and stated the stat x-rays were not obtained during her shift. The facility’s portable x-ray contract stated the response time for stat x-rays would be two and a half hours or less.
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What surveyors actually found near you
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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 Seaman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eagle Creek Nursing Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Adams County Manor | 12.9 mi | ★★★★★ | 18 | 0 |
| Hillsboro Health And Rehab Llc | 16.6 mi | ★★★★★ | 3 | 1 |
| Crestwood Ridge Skilled Nursing And Rehab | 17.2 mi | ★★★★★ | 0 | 0 |
| Hillsboro Post Acute | 17.9 mi | ★★★★★ | 0 | 0 |
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