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 Manor during CMS and state inspections, most recent first.
An IJ situation arose when a resident's tracheostomy cannula became dislodged, and the agency nurse failed to reinsert it, provide oxygen, or address bleeding. The resident, diagnosed with malignant neoplasm of the supraglottis, was found bleeding and later passed away. The facility lacked training and orientation for agency nurses, contributing to the deficiency.
A resident with emphysema and muscle weakness experienced increased pain after a fall, which was not documented or assessed by the facility staff. Despite receiving multiple doses of morphine for high pain levels, the fall was only discovered when the resident was sent to the ER for other symptoms. The DON was unaware of the fall until informed by the ER physician, revealing a lapse in communication and protocol adherence by the staff.
A resident with dysphagia and dementia had a dislodged PEG tube, which was not assessed or reported to a physician immediately. The incident was documented by a nurse, but the information was only passed to the next shift without proper action. The resident was later assessed and sent to the hospital. Staff interviews confirmed the expectation for immediate assessment and physician notification.
The facility failed to monitor side effects for a resident on psychotropic medications, did not limit a PRN antianxiety medication to 14 days for another resident, and did not address a pharmacist's dose reduction recommendation for a third resident. The DON and LPNs confirmed the lack of documentation and physician response.
The facility failed to prevent residents and visitors from accessing an unlocked ice chest, breaching infection control standards. Despite policy stating only staff should handle ice, observations showed residents and visitors using the ice scoop, with some touching the ice directly. Staff interviews confirmed this practice, and the DON acknowledged it as an infection control issue.
The facility failed to implement a system for preventing Legionnaire's disease and did not follow proper infection control practices during wound care for two residents. Staff did not use enhanced barrier precautions or perform hand hygiene appropriately, leading to deficiencies in infection prevention.
A resident with dementia and a history of elopement attempts was observed opening a locked lobby door, but the care plan was not revised to address this risk. The care plan included interventions unrelated to elopement, and despite implementing interventions after the incident, they were not documented. The MDS Coordinator and DON acknowledged the oversight in care planning.
The facility did not ensure influenza vaccinations were offered to two residents, despite having a policy requiring annual offers of the vaccine to all residents, staff, and volunteers. The immunization records for these residents, who had conditions such as diabetes, hypertension, and cerebral palsy, lacked documentation of receiving or being offered the flu vaccine. The infection preventionist confirmed the absence of such documentation.
A resident with joint replacement surgery and osteoarthritis experienced inadequate pain management, reporting a pain level of eight. Despite a physician's order for pain medication, it was not administered until the next day. The facility lacked documentation of physician contact or non-pharmacological interventions. Staff acknowledged the need for expedited medication delivery and nursing interventions. The administrator could not find a relevant policy, and the medication was delayed until pharmacy delivery.
A facility failed to report an allegation of verbal abuse to the Oklahoma State Department of Health within the required timeframe. A resident reported verbal abuse by staff, which was witnessed by the DON, who did not initially perceive it as abuse. The DON, on leave, advised the BOM to inform the administrator. The administrator, informed of the allegation, assumed the DON would report it upon returning. The incident, occurring on 05/09/24, was not reported until 05/20/24, missing the 24-hour reporting requirement.
A facility failed to investigate an abuse allegation and suspend the alleged perpetrator. A resident reported verbal abuse by a CMA, but the DON, who witnessed the interaction, did not perceive it as abuse. The DON instructed the CMA not to work with the resident but allowed them to continue working with others. The Administrator did not initiate an investigation, assuming the DON would handle it. The DON later acknowledged that no investigation was conducted, and the CMA should have been suspended.
The facility failed to notify a resident's physician after a significant weight loss. The resident, diagnosed with Alzheimer's dementia and nutritional anemia, experienced a weight drop from 120 lbs. to 104 lbs. Despite care plan instructions to contact the physician, the DON confirmed that the physician was not informed.
A resident with diabetes mellitus did not receive necessary treatment and services consistent with standards of practice. The resident's diabetic condition was not documented in the baseline care plan or admission MDS, and there was no monitoring of blood sugar or A1c levels upon admission. This led to a severe hypoglycemic event, requiring emergency medical intervention.
A resident with a history of falls experienced 15 falls over 50 days, resulting in multiple injuries, including two subdural hematomas. Despite a high risk for falls, the facility's interventions were limited and ineffective, and the care plan was not updated with specific measures. The facility did not follow its Fall Prevention Policy, leading to repeated falls and serious injuries.
The facility failed to protect a resident's dignity by allowing him to remain naked and visible from the hallway on multiple occasions. Despite the resident's noncompliance, staff acknowledged that better measures should have been taken to ensure his dignity.
Failure to Provide Appropriate Tracheostomy Care
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified at a facility due to the failure to provide appropriate tracheostomy care for a resident. The incident occurred when an agency nurse discovered that a resident's inner tracheostomy cannula had become dislodged, and the resident was bleeding from the tracheostomy site. The nurse failed to attempt reinsertion of the cannula, did not provide oxygen, did not address the bleeding, and did not remain with the resident. The resident, who had a diagnosis of malignant neoplasm of the supraglottis and tracheostomy status, was found with the trach tube in their hand and bleeding profusely. Despite the nurse's call to 911, the resident was no longer breathing and had no pulse upon EMS arrival, and subsequently passed away. The facility's policy on tracheostomy care included steps for accidental decannulation, such as calling for help and attempting to reinsert a new sterile tracheostomy tube. However, the agency nurse did not follow these procedures. Additionally, it was revealed that agency nurses had not received training for emergency decannulation, and there was no formal orientation procedure for agency nurses at the facility. The Director of Nursing (DON) confirmed the lack of training and orientation for agency staff, which contributed to the deficiency in care provided to the resident.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to properly assess, monitor, and intervene for a resident who experienced increased pain following a fall, which resulted in a hip fracture. The resident, who had diagnoses including emphysema and muscle weakness, was initially independent in daily decision-making and required moderate assistance with activities of daily living. A physician's order was in place for morphine sulfate to be administered as needed for pain. The resident's pain levels increased significantly over several days, with documentation showing multiple doses of morphine administered for high pain levels. Despite this, there was no documentation of a fall or subsequent assessment by nursing staff until the resident was sent to the emergency room for shortness of breath, confusion, and right-side pain. The deficiency was further highlighted when the Director of Nursing (DON) was informed by the emergency room physician that the resident had reported a fall, which the facility was unaware of. An investigation revealed that the resident had reported the fall to a CNA, who then informed an RN. However, there was no documentation of an assessment, physician notification, or incident report by the RN. The resident was later found to have a broken hip and had been requesting pain medication more frequently than usual. Interviews with various staff members, including agency nurses and LPNs, confirmed that the protocol for fall assessment and physician notification was not followed, leading to a delay in addressing the resident's injury and pain management needs.
Failure to Assess and Notify Physician of Dislodged PEG Tube
Penalty
Summary
The facility failed to perform an assessment and notify the physician of a dislodged PEG tube for one of the three sampled residents reviewed for feeding tubes. The resident, who had diagnoses including dysphagia and dementia, had a care plan intervention initiated to monitor and report any signs of the tube becoming dislodged. On January 12, 2024, a nurse's note documented that the resident pulled the PEG tube out approximately 2 inches, and the nurse was unable to replace it. The information was passed to the night nurse to report to the day nurse, but there was no documentation of an assessment or physician notification. The following day, the resident was assessed and sent to the hospital for evaluation and treatment. Interviews with nursing staff and the DON confirmed that the expectation was for the physician to be notified immediately and the resident assessed if a PEG tube was dislodged.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper side effect monitoring for a resident with major depressive disorder and insomnia who was receiving psychotropic and antidepressant medications. Despite care plan interventions requiring monitoring every shift, the resident's medical records lacked documentation of such monitoring. Interviews with LPNs and the DON confirmed that side effect monitoring should be documented in the Treatment Administration Record (TAR), but this was not done for the resident in question. Another deficiency involved a resident with anxiety disorder and depression who was prescribed diazepam as a PRN medication without a stop date, exceeding the 14-day limit for PRN psychotropic medications. The DON was unable to explain why the order was PRN or why it was extended beyond the recommended duration. Additionally, a resident with major depressive disorder was prescribed Latuda, an antipsychotic medication, without a physician's response to a pharmacist's recommendation for a gradual dose reduction. The facility's administrator and DON acknowledged the lack of documentation and response from the physician regarding the dose reduction recommendation.
Infection Control Breach: Unrestricted Ice Access
Penalty
Summary
The facility failed to ensure that an unlocked container of ice was not utilized by residents and visitors, which is a breach of infection control standards. The facility's policy stated that only employees should obtain ice using sanitary methods, and only employees may use an ice scoop if needed. However, observations on multiple occasions revealed that an ice chest located in the hallway across from the nurses' station was full of ice, with an ice scoop next to it, and was not locked. This allowed residents and visitors to access the ice directly. Interviews with staff members, including CNAs and the dietary manager, confirmed that residents and visitors were accessing the ice themselves, contrary to the facility's policy. A resident was observed using the ice scoop but touched the ice with their hand repeatedly. The dietary manager and the Director of Nursing (DON) acknowledged that the ice was intended for staff to distribute to residents and that allowing residents and visitors to access it themselves posed an infection control issue. The DON confirmed that the staff's actions were not in line with infection control standards or facility policy.
Infection Control Deficiencies in Wound Care and Legionnaire's Disease Prevention
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of a system for surveillance and monitoring to prevent Legionnaire's disease. The maintenance supervisor and infection preventionist both confirmed the absence of a water management program, and the Director of Nursing (DON) acknowledged the need for such a program. This deficiency highlights a significant gap in the facility's infection control measures, particularly concerning waterborne pathogens. Additionally, the facility did not adhere to proper infection control practices during wound care for two residents. One resident with a pressure ulcer and diabetes mellitus received wound care from the DON and a CNA without the use of enhanced barrier precautions, such as wearing gowns. The DON also failed to perform hand hygiene when changing gloves multiple times during the procedure. Another resident with a stage four pressure ulcer expressed concerns about the frequency of bandage changes. An LPN providing wound care did not change gloves or perform hand hygiene after touching a bed pad before handling wound packing material. The DON later confirmed that the LPN did not follow the standards of care and facility policy.
Failure to Revise Care Plan After Elopement Attempt
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of elopement attempts after an incident where the resident was observed opening the facility's locked lobby door. The resident, diagnosed with dementia, had a care plan focus on elopement risk, which included interventions to assess for falls and identify reasons for elopement attempts. However, these interventions were not updated following an incident on June 29, 2024, when the resident attempted to leave the facility through the locked front door. Despite the incident, the care plan remained unchanged, and the intervention to assess for falls was deemed irrelevant to the elopement risk by the MDS Coordinator. The Director of Nursing acknowledged that interventions were implemented following the attempted elopement but were not documented in the care plan. This oversight highlights a failure to ensure the care plan was accurately revised to address the resident's elopement risk effectively.
Failure to Offer Influenza Vaccinations to Residents
Penalty
Summary
The facility failed to ensure that influenza vaccinations were offered to two residents, identified as #32 and #34, out of five residents reviewed for immunizations. Resident #32, who had diagnoses including diabetes mellitus and hypertension, did not have documentation in their immunization record indicating that they had received or been offered a flu vaccination. Similarly, Resident #34, with diagnoses including cerebral palsy and hypertension, also lacked documentation of having received or been offered a flu vaccination. The facility's undated Influenza and Pneumonia Immunization Policy stated that all residents, staff, and volunteers would be offered the influenza vaccine annually, with documentation required in the residents' clinical records. However, the infection preventionist confirmed that no documentation regarding the vaccination status of Residents #32 and #34 was found.
Failure in Pain Management for Post-Surgery Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. The resident, who had undergone joint replacement surgery and had osteoarthritis, reported a pain level of eight. Despite a physician's order for oxycodone-acetaminophen to be administered every six hours as needed, the resident did not receive the medication until the following day at 3:30 am. The clinical record lacked documentation of any contact with the physician regarding the resident's pain level or attempts at non-pharmacological interventions. Staff interviews revealed that the physician or pharmacy should have been contacted to expedite medication delivery, and nursing interventions like positioning or ice packs should have been attempted. The administrator was unable to locate a policy related to pharmacy services or pain management, and the medication was not available until delivered by the pharmacy company.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health within the mandated time frame for one of the three sampled residents reviewed for abuse. The facility's policy required notification to the State Department of Health within 12 hours of an incident. An incident report documented that an allegation of verbal abuse by a resident occurred on 05/09/24, but the report was not sent to the OSDH until 05/20/24. The Director of Nursing (DON) witnessed a verbal interaction on 05/09/24 but did not initially perceive it as abuse. On 05/10/24, the Business Office Manager (BOM) informed the DON, who was on leave, that the resident reported verbal abuse. The DON advised the BOM to inform the administrator. The administrator was informed on 05/10/24 but did not report the allegation, assuming the DON would do so upon returning on 05/13/24. Consequently, the 24-hour reporting requirement was not met.
Failure to Investigate Abuse Allegation and Suspend Alleged Perpetrator
Penalty
Summary
The facility failed to investigate an allegation of abuse and suspend the alleged perpetrator during the investigation process. An incident report documented an allegation of abuse by a resident that occurred on a specific date. The Director of Nursing (DON) witnessed a verbal interaction between the resident and a Certified Medication Aide (CMA) but did not perceive it as abuse at the time. The DON instructed the CMA not to work with the resident after the incident but allowed the CMA to continue working with other residents. The DON was informed of the resident's abuse allegation while on leave and advised that the administrator should be informed, but believed an investigation was never conducted. The Administrator, upon being informed of the allegation, did not initiate an investigation, assuming the DON would handle it upon their return. The CMA was not suspended, as the DON had instructed them not to work with the resident, and the Administrator believed this instruction was followed. The DON later confirmed that an incident report was sent to the relevant authorities but acknowledged that no investigation was conducted, and the CMA should have been suspended during the investigation.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician after a significant weight loss for one of the three sampled residents reviewed for weight loss. The resident had diagnoses including Alzheimer's dementia, nutritional anemia, and acquired absence of parts of the digestive tract. The care plan, dated 08/22/23, indicated that staff should contact the physician and dietitian immediately if weight loss continued. The resident's weight dropped from 120 lbs. on 12/28/23 to 104 lbs. on 01/23/24. Despite this significant weight loss, the physician was not notified. The Director of Nursing (DON) confirmed that the physician had not been informed of the resident's weight loss in January 2024.
Failure to Provide Necessary Diabetic Care
Penalty
Summary
The facility failed to ensure a resident with diabetes mellitus received necessary treatment and services consistent with standards of practice. The resident had diagnoses including diabetes mellitus and cysts of the pancreas. Despite a physician order for glimepiride, a diabetic medication, the baseline care plan and admission MDS did not document the resident's diabetic condition. Additionally, there was no documentation of blood sugar or A1c monitoring upon admission. This oversight led to an unwitnessed fall where the resident was found unresponsive with a serum glucose level of less than five upon admission to the emergency room. The Director of Nursing (DON) acknowledged the facility's awareness of the resident's diabetic condition upon admission and admitted that the baseline care plan and admission MDS were likely rushed, resulting in the omission of critical diabetic care documentation and monitoring. The DON also stated that nurses should follow physician orders and monitor residents for signs and symptoms of hypoglycemia and hyperglycemia. However, it was noted that it is unusual for a diabetic resident not to have an A1c ordered on admission and quarterly. The lack of proper documentation and monitoring led to the resident experiencing a severe hypoglycemic event, which was only addressed after the resident was found unresponsive and required emergency medical intervention.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to prevent falls and minimize injuries for a resident with a history of falls and depression. The resident experienced 15 falls over a period of 50 days, resulting in multiple injuries, including facial lacerations, hematomas, and two subdural hematomas. Despite the high risk for falls indicated by a Morse Fall Scale score of 80, the facility's interventions were limited to reminders to use the call light and wear non-slip socks, which were ineffective given the resident's condition and noncompliance. The facility's documentation revealed a pattern of inadequate response to the resident's falls. Multiple fall notes indicated that the resident was found on the floor on several occasions, often with injuries, but no new or effective interventions were documented. The care plan was not updated with specific, actionable interventions, and the facility's staff, including the DON and MDS coordinator, acknowledged that the existing measures were not effective. The resident's condition, including intermittent confusion and inability to understand how to use the call light, was not adequately addressed in the care plan. The facility's Fall Prevention Policy stated that the care plan should include goals, interventions, and approaches for residents at risk for falls, and that these should be evaluated by the QA committee. However, the facility did not follow this policy, as evidenced by the lack of effective interventions and the absence of an at-risk plan for the resident. The DON admitted that the interventions were not effective, and the MDS coordinator stated that the facility no longer used at-risk plans, despite their inclusion in the care plan. This failure to implement and evaluate appropriate fall prevention measures led to repeated falls and serious injuries for the resident.
Failure to Protect Resident's Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident was protected. The resident, who had diagnoses including cirrhosis of the liver and frequent falls, was observed on multiple occasions laying naked on a fall mat in his room with the door open, making him clearly visible from the hallway. This occurred on three separate occasions on 01/17/24 at 8:30 a.m., 12:32 p.m., and 2:22 p.m. Staff and other residents were observed walking up and down the hallway during these times. On 1/18/24, a CNA acknowledged that the resident should not have been exposed in such a manner, and another CNA admitted that while the resident was noncompliant, better measures should have been taken to protect his dignity. The DON also confirmed that steps should have been taken to protect the resident's dignity.
What surveyors are citing around you — mapped
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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 24 citations issued within 25 miles in the last 12 months — including the 3 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 Jay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Betty Ann Nursing Center | 10.5 mi | ★★★★★ | 1 | 0 |
| Grove Nursing Center | 10.5 mi | ★★★★★ | 0 | 0 |
| Grand Lake Villa | 10.6 mi | ★★★★★ | 10 | 3 |
| Quail Ridge Living Center, Inc | 21.3 mi | ★★★★★ | 0 | 0 |
| Siloam Healthcare, Llc | 21.3 mi | ★★★★★ | 0 | 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.