Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Health & Rehab Center during CMS and state inspections, most recent first.
Food was improperly stored and handled in the kitchen when surveyors observed an uncovered container of powdered thickener with a scoop inside, wet stacked pans, a cloth on the refrigerator floor, and buffet ham stored above produce. Freezer #2 was also found at an improper temperature with water accumulation, wet boxes, and multiple food items that were not fully frozen, while staff reported the unit had been overpacked and the door may not have been fully closed.
A resident’s admission MDS was inaccurately coded in section A1550 for ID/DD conditions. The resident had Coffins-Siris Syndrome with developmental delays and intellectual disability, a PASSR Level I referral for a Level II assessment, and a Level II assessment confirming the diagnosis, yet the MDS showed no ID/DD condition and a BIMS score of 15 indicating cognitive intactness.
Two residents lacked CCPs for tube-related care and enhanced barrier precautions. One resident had a PEG tube for nutritional support and the other had a g-tube for water flushes only; both were cognitively intact and had PPE/signage observed outside their rooms, but their records did not include CCPs for the tube care or EBP.
Failure to revise care plans for comfort care and behavioral symptoms: one resident with severe cognitive impairment and multiple chronic diagnoses had a provider order for comfort care that was not reflected in the care plan when ordered, and another resident with bipolar disorder and dementia had repeated documentation of yelling, cursing, and aggression while the behavioral care plan interventions remained unchanged despite ongoing behaviors.
Failure to provide ADL assistance for a resident with vascular dementia and major depressive disorder was identified when the resident was observed with long, jagged fingernails despite a care plan calling for nail checks and trimming as needed. The resident, who was cognitively intact and required partial/moderate assistance with personal hygiene, reported that someone said they would trim the nails but did not return.
Facility staff failed to follow physician/provider orders for three residents. One resident with severe cognitive impairment and eye pain/osteoarthritis diagnoses missed ordered GenTeal eye drops and Voltaren gel because the meds were documented as unavailable. A cognitively intact resident missed an ordered methocarbamol dose for the same reason. Another resident on comfort care with an order for no weights still had monthly weights obtained, despite the care plan also directing no weights.
A physician failed to review a resident’s total plan of care, including meds, at required visits. The resident was observed with containers of Beet Root Heart Gummies and Sea Veg on the bedside table and stated he had ordered the supplements online and was taking them to improve his health. The Medical Director said he knew the resident was taking Beet Root Heart Gummies but did not check the MAR to see whether the supplements or other items were listed, and he knew the resident did not self-administer meds.
A resident with HTN, HF, and hypothyroidism had Beet Root Heart Gummies and Sea Veg left unsecured on his bedside table and within reach. The resident said he ordered the supplements online and was taking them to improve his health, but there was no provider order and they were not on the MAR. The supplement labels included cautions about use with other meds and, for Sea Veg, with thyroid meds. An LPN said staff were unaware the items were at the bedside.
Failure to use ordered adaptive eating equipment for a resident with severe cognitive impairment. The resident had provider orders for a plate guard and a two-handled cup with lid, and the care plan identified adaptive equipment in place, but staff did not set up the meal as ordered. The resident’s family reported the plate guard was not being placed on the plate, and surveyors observed the equipment sitting unused while the resident ate breakfast; a CNA later acknowledged the meal had not been set up and then corrected it.
The facility failed to maintain infection control practices for two residents. One resident with Influenza B had droplet/contact precautions ordered, but an Activities Assistant entered the room wearing only a mask and a CNA entered with no PPE despite the posted precaution sign. Another resident with dry eye syndrome received eye drops from an LPN, who used the same tissue to wipe both eyes instead of using separate tissues as required by policy to prevent cross contamination.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident undergoing chemotherapy was allowed to keep and self-administer an inhaler and pain ointments at the bedside without a prior assessment of their ability to do so safely. Staff interviews and record reviews confirmed that the required self-administration assessment and care plan updates were not completed before medications were left in the resident's room, contrary to facility policy.
A resident with multiple medical conditions did not have a personal property inventory completed upon admission, contrary to facility policy. The resident later reported missing medication and gift cards, and staff were unable to locate any documentation of the resident's property. Interviews confirmed the absence of the inventory form, and the facility's grievance logs showed the missing items were reported and investigated.
Two residents who sustained skin injuries did not have comprehensive wound assessments or immediate care interventions properly documented by staff. In both cases, only minimal details were recorded, with missing information on wound size, appearance, and care provided, despite facility policy requiring detailed documentation. Interviews with the DON and an LPN confirmed that superficial wounds were not fully documented, and only treatment orders were entered.
Staff failed to transcribe and implement physician orders for compression bandages, ace wraps, and discontinuation of furosemide for two residents. A resident was admitted with orders for compression therapy that were not entered into the record, and subsequent orders for ace wraps and medication changes were also missed. Interviews and documentation review revealed that nursing staff did not follow facility policy for transcribing and confirming physician orders, leading to a lapse in care.
Staff did not provide a resident with continuous oxygen therapy as ordered by the physician, and failed to label or date the oxygen tubing and humidifier bottle. The oxygen equipment was present but not in use, and documentation inaccurately reflected that therapy had been administered. Facility policy requiring proper administration and labeling was not followed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with dementia and a history of falls experienced multiple falls in one day, resulting in injuries. Despite the incidents, the facility staff failed to document an assessment after one of the falls. The resident was later found with rib fractures and a lacerated spleen. The nurse involved did not document the assessment and was unavailable for an interview.
A resident with dementia and a history of falls experienced multiple falls in one day, leading to serious injuries. The falls were not accurately documented by the nursing staff, as they assumed others would record the incidents. This lack of documentation was later acknowledged by the facility's DON.
Improper Food Storage and Freezer Temperature Control
Penalty
Summary
Food was not properly stored, prepared, and distributed in the facility kitchen. During the initial kitchen tour on 04/21/2026, surveyors observed a clear plastic container of powdered thickener without a lid and with a scoop inside, stacked silver pans with visible water droplets, a white cloth lying on the bottom of refrigerator #1, and a roll of buffet ham stored on a shelf above produce. The Dietary Manager confirmed the ham should not have been stored above produce. Dietary Aide #1 removed the scoop and staff removed the cloth when observed. Surveyors also found freezer #2 not maintaining proper temperature, with an internal temperature of 16 degrees Fahrenheit, water accumulation on the bottom shelf, wet cardboard boxes, and multiple food items that were not fully frozen, including sherbert, vegetables, meats, soups, and other prepared items. Staff stated the food had been delivered the previous day and did not access it for breakfast. The Dietary Manager stated the unfrozen items would be discarded and reported previous issues with the freezer. The Maintenance Director stated the freezer was new and may have been overpacked, and later the Administrator stated the freezer door had been left ajar and the unit was too full of product, causing it to freeze up.
Inaccurate MDS Coding for ID/DD Condition
Penalty
Summary
The facility failed to accurately complete the admission MDS assessment for Resident #84 by incorrectly coding section A1550 for conditions related to intellectual and/or developmental disabilities (ID/DD). Resident #84 had a documented diagnosis of Coffins-Siris Syndrome, a genetic disorder characterized by developmental delays and intellectual disability. The admission MDS assessment with an ARD of 02/26/2026 included a BIMS score of 15, indicating the resident was cognitively intact, and section A1550 was coded to show no conditions related to ID/DD. However, the clinical record included a Level I PASSR dated 02/20/2026 that referred the resident for a Level II assessment due to IDD or a related condition, and the Level II assessment confirmed a diagnosis of Coffins-Siris Syndrome prior to age [AGE]. During an end of day meeting on 04/21/2026, the inaccurate coding was reviewed with facility leadership, and on 04/22/2026 the DON provided an updated MDS stating the assessment had been modified.
Missing CCPs for PEG/G-Tube Care and Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to develop comprehensive care plans for enhanced barrier precautions for two residents. Resident #11 had a PEG tube for nutritional support, diagnoses of malignant neoplasm of the tonsils and Parkinson’s disease, and a BIMS score of 15 indicating cognitive intactness. Although an enhanced barrier precautions sign and PPE were observed outside the resident’s room and staff were seen using PPE in the room, the clinical record did not contain a CCP for enhanced barrier precautions. The resident also had a provider order for enteral-bolus tube feeding four times a day, and the facility later identified enhanced barrier precautions for the PEG tube in an updated CCP. Resident #105 also did not have a CCP for the g-tube or enhanced barrier precautions. This resident had a g-tube used for water flushes only, diagnoses of Guillain-Barre syndrome and polyneuropathy, and a BIMS score of 15 indicating cognitive intactness. During the initial tour, an enhanced barrier precautions sign and PPE were observed outside the resident’s room. The clinical record included a provider order for 60 cc of water via g-tube every shift, but the CCP did not identify the g-tube flush or enhanced barrier precautions. The MDS nurse reviewed the record and confirmed there was no care plan in place for the g-tube or enhanced barrier precautions.
Failure to Revise Care Plans for Comfort Care and Behavioral Symptoms
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for Resident #58 after a provider order for comfort care measures was started. Resident #58 had diagnoses including atherosclerotic heart disease status-post CABG, sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit, and the most recent MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The provider order directed comfort care with no labs, no IVs, no weights, and no hospitalization, but the care plan did not reflect this order until an audit was completed later. The DON acknowledged that comfort care was not added to the care plan when the order was initiated and stated it was added during the later audit. The facility also failed to revise the care plan for Resident #138 to include updated interventions for continued and escalating behavioral symptoms. Resident #138 had a history of bipolar disorder and dementia with other behavioral disturbance, and the most recent quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The behavioral care plan, initiated earlier, continued to list the same interventions while the problem statement was repeatedly revised to document yelling, cursing at staff, and aggression with care. The MDS Coordinator stated that interventions were not always updated, that redirection worked best, and that the existing interventions did not appear effective, adding that additional interventions should have been considered and added to address the ongoing behaviors.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to provide ADL care for Resident #7, who had diagnoses of vascular dementia and major depressive disorder and was assessed as cognitively intact with a BIMS score of 15. The resident’s admission MDS indicated partial/moderate assistance was needed with personal hygiene, and the comprehensive care plan identified a need for assistance with ADLs including dressing, grooming, toileting, feeding, and oral care, with an approach to check nail length and trim and clean as needed per protocols. During observation and interview on 04/21/2026, Resident #7 was noted to have long, jagged fingernails, and the resident stated that someone had said they would trim the nails but did not return. The issue was reviewed later that day with facility leadership, and on the following day the resident’s fingernails were observed to have been trimmed.
Failure to Follow Physician Orders for Medications and Weights
Penalty
Summary
Facility staff failed to follow physician orders for Resident #15 by not administering GenTeal eye drops and Voltaren gel as ordered. Resident #15 had diagnoses including other corneal scars and opacities and primary osteoarthritis, and the quarterly MDS indicated severe cognitive impairment. The care plan included interventions to administer medications as ordered and to administer eye medication as ordered. The physician’s orders directed Voltaren Arthritis Pain gel to both knees twice daily and GenTeal Tears to the left eye twice daily for dry eyes, but the eMAR showed multiple doses of GenTeal coded as not administered because the drug was unavailable and one missed dose of Voltaren gel coded the same way. Facility staff also failed to administer methocarbamol to Resident #120 as ordered. Resident #120 had a diagnosis of other muscle spasm and was cognitively intact based on the quarterly MDS. The physician’s order directed methocarbamol 750 mg by mouth twice daily, but the April 2026 eMAR showed one morning dose coded as not administered because the drug was unavailable. The DON stated the nurse who administered medications on that date was a new employee and did not know where to look for the medication, and that the medication was available for administration. Facility staff further failed to follow a provider order for Resident #58 by obtaining monthly weights despite an order for comfort care and no weights. Resident #58 had diagnoses including atherosclerotic heart disease, sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit, and the MDS indicated severe cognitive impairment. A provider order with a start date of 2/21/26 stated comfort care and no weights, and the care plan also included no weights. However, the weight record showed weights were obtained on 3/6/26 and 4/3/26, and the DON stated those weights were obtained in error.
Physician Did Not Review Resident’s Medication and Supplement Use at Required Visits
Penalty
Summary
The facility physician failed to review the resident’s total program of care, including medications, at each required visit for Resident #87. On 4/21/2026, the resident was observed asleep in bed with containers of Beet Root Heart Gummies and Sea Veg on the bedside table, both identified as nutritional supplements. During an interview later that morning, the resident again had both supplement containers on the bedside table and stated that he had ordered them online and was taking them to improve his health. On 4/22/2026, the Medical Director stated he had become aware a couple of weeks earlier that the resident was taking Beet Root Heart Gummies, but he did not check the resident’s MAR to determine whether the supplements or other items were listed. The Medical Director also stated he was aware that the resident does not self-administer medications.
Unsecured Supplements Found at Resident Bedside
Penalty
Summary
The facility failed to ensure the safe storage of biologicals for one resident, who was admitted with a history of hypertension, heart failure, and hypothyroidism and was cognitively intact on the most recent MDS. The resident had been assessed and did not wish to self-administer medications. His current orders included levothyroxine daily, bumetanide daily, and Entresto twice daily. During observation, a container of Beet Root Heart Gummies and a container of Sea Veg were found unsecured on the resident’s bedside table and within reach while he was asleep in bed and later during an interview. The resident stated he had ordered the items online and was taking them to improve his health. The facility’s records did not show a provider order for either supplement, and neither item appeared on the April 2026 MAR. The product label for Beet Root Heart Gummies advised consulting a physician before use when taking other medications or with medical conditions, and the Sea Veg label advised consulting a physician before use if taking thyroid medications. The DON and Administrator were informed of the supplements at the bedside, and an LPN stated the resident often had items delivered to his room and that staff were not aware the supplements were present at the bedside.
Failure to Use Ordered Adaptive Eating Equipment
Penalty
Summary
Facility staff failed to use ordered adaptive eating equipment for Resident #58, including a plate guard and a two-handled cup with lid, during meals. Resident #58 had diagnoses including sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit, and the most recent MDS dated 1/26/26 showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The resident’s medical provider orders dated 1/23/26 included adaptive feeding equipment for a plate guard with meals and a two-handled cup with lid, and the care plan also identified adaptive equipment in place. On 4/21/26, the resident’s family member stated that staff failed to put the plate guard on the resident’s plate. On 4/22/26, the resident was observed eating breakfast from a plate on the over-the-bed table, with the plate lid on the bed and the plate guard and two-handled cup with lid sitting inside the lid. The resident requested black coffee, and a CNA stated she had not set up the meal but would correct it; she then placed the plate guard on the plate and said she would put the coffee in the two-handled cup. The facility policy stated adaptive eating devices are provided per provider order.
Infection Control Failures During Isolation and Eye Drop Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 2 residents. For one resident with quadriplegia, COPD, CHF, and cough, the clinical record showed an order for combined droplet/contact precautions related to Influenza B, and the care plan directed staff to follow droplet precautions/isolation, use PPE, and keep the door closed. During observation, the resident’s door was closed and a droplet-contact precaution sign was posted, but an Activities Assistant entered after reading the sign and wore only a mask, without gown or gloves. A CNA then entered the room without any PPE and later stated she was not aware the resident was on droplet precautions and did not see the sign. For another resident with dry eye syndrome and severe cognitive impairment, the MAR ordered Refresh Classic eye drops, 2 drops in both eyes. During medication administration observation, an LPN gave the drops to both eyes and then used the same tissue to wipe both eyes, moving from the inner to outer corner of each eye with the same tissue. The facility policy stated that two different tissues should be used, one for each eye, to prevent cross contamination.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pest infestations within the facility. No additional details regarding specific residents, staff, or observed pests were provided in the report.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident's ability to safely self-administer medications prior to allowing the resident to keep and use medications at the bedside. Observations revealed that the resident had an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 stored in a basket at the bedside. The resident reported using the pain ointments for relief during chemotherapy and self-administering the inhaler twice daily, with the nurse leaving the inhaler in the room for the resident to use. Interviews with staff indicated that there was a process for approving self-administration, but in this case, no assessment had been completed before the medications were left at the bedside. Further review of the clinical record confirmed the absence of a self-administration assessment and that the resident's care plan did not address self-administration of medications. The Minimum Data Set did not indicate that the resident was independent with medications. Facility policy required an assessment to ensure residents could safely self-administer and store medications in a locked compartment, but these steps were not followed prior to the medications being left at the bedside.
Failure to Document and Protect Resident Personal Property
Penalty
Summary
The facility failed to ensure reasonable care for the protection of personal property for one resident. Upon admission, no personal property inventory form was completed for the resident, despite facility policy requiring this documentation. The resident, who had diagnoses including contusion of the left lower leg, status post left knee surgery, obesity, depression, kidney disease, and deep vein thrombosis, was cognitively intact at the time of the incident. The absence of an inventory form was confirmed through clinical record review and staff interviews. The resident reported missing personal items, specifically two gift cards and medication (Ozempic) that had been brought from home. Investigation into the missing items revealed that the facility did not have documentation of the resident's property upon admission or during the stay. Staff interviews confirmed that the inventory form could not be located, and the DON acknowledged that medications would not be listed on the property form but would be stored with the resident's name. The facility's grievance logs showed the missing items were reported and investigated, but the lack of an initial inventory form contributed to the deficiency.
Failure to Document Comprehensive Wound Assessments and Immediate Care
Penalty
Summary
Facility staff failed to follow professional standards of care regarding assessment documentation for two residents who sustained skin injuries. In the first case, a resident with multiple medical conditions, including anemia, HIV, and chronic kidney disease, experienced a fall in a transportation van resulting in a skin tear to the left lower extremity. The only documentation provided was a brief mention of the injury's location and minimal details about swelling and pain. There was no description of the wound's size, appearance, bleeding status, or surrounding tissue, nor was there documentation of immediate care provided, such as cleansing or dressing application. Nursing notes for the date of the incident were absent, and while the physician was reportedly notified, there was no record of care orders or the physician's response. In the second case, another resident sustained a laceration to the right leg during a transfer with a mechanical lift and later a skin tear to the right flank after rolling off the bed. Initial documentation for both incidents lacked detailed wound assessments, including measurements, wound characteristics, and immediate interventions. The first detailed wound assessment was not recorded until the day after the injury, despite treatment orders being in place. Interviews with staff indicated that superficial wounds were not documented in detail, and the director of nursing confirmed that only treatment orders were entered for such injuries. Facility policies required comprehensive documentation and assessment following incidents, including wound characteristics such as location, size, exudate, pain, wound bed, and surrounding tissue appearance. These requirements were not met in the cases reviewed, as evidenced by the lack of descriptive assessments and immediate care documentation. The findings were discussed with facility leadership, and no additional information was provided to address the documentation deficiencies.
Failure to Transcribe and Implement Physician Orders for Compression Therapy and Medication
Penalty
Summary
Facility staff failed to follow physician orders for two residents by not transcribing and implementing orders for compression bandages, ace wraps, and discontinuation of furosemide. One resident was admitted with an order for compression bandages, but this order was not transcribed at admission. The resident’s spouse reported that lower extremity treatments were not being performed as expected. Staff interviews revealed that the initial order for Pro-fore wraps was missed, and when those wraps were used up, staff switched to ace wraps per the physician’s order, but this order was also not properly documented. The physician confirmed that he had ordered ace wraps to be applied daily and had discontinued furosemide, but these orders were not entered into the clinical record. Further review of the clinical record and facility documentation showed that the required process for transcribing and confirming physician orders was not followed. The facility’s policy required that all physician orders, including those from hospital discharge summaries and verbal orders, be transcribed and reviewed by the charge nurse. However, the orders for compression bandages, ace wraps, and discontinuation of furosemide were not entered into the system, and staff interviews indicated confusion about who was responsible for entering these orders. The Director of Nursing confirmed that providers do not enter orders and that it is the responsibility of the nursing staff, but the necessary orders were not transcribed, resulting in a failure to provide care according to physician instructions.
Failure to Administer Ordered Oxygen Therapy and Label Equipment
Penalty
Summary
Facility staff failed to administer oxygen therapy as ordered by the physician for one resident. Observations revealed that the resident was not receiving continuous oxygen via nasal cannula at two liters, as prescribed. The oxygen concentrator was present in the resident's room, but the humidifier bottle was found on the floor and there was no oxygen tubing connected to the concentrator. The resident's spouse confirmed that the oxygen had not been in use since the previous day, and that the tubing had been removed from the room. Multiple observations throughout the day confirmed that the resident was not receiving oxygen as ordered, and staff had not checked on the resident's oxygen levels during this period. Further review showed that the oxygen tubing and humidifier bottle were not labeled or dated, as required. The clinical record indicated that the oxygen order had been signed off as administered, despite the resident not receiving it. The care plan also reflected the need for continuous oxygen at two liters via nasal cannula. Facility policy required licensed clinicians to administer oxygen as ordered, but this was not followed in this instance. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Document Assessment After Resident Falls
Penalty
Summary
The facility staff failed to complete an assessment after a fall for a resident diagnosed with dementia, manic depression, and fractures secondary to falls. The resident, who was severely cognitively impaired, experienced multiple falls on the same day. Initially, a fall occurred at 4:16 AM, and a full assessment was completed without noting any injuries. However, later that day, the resident was found confused, lethargic, and hypotensive, leading to a hospital transfer where rib fractures and a lacerated spleen were diagnosed. A subsequent fall occurred around 8:00 AM, where the resident was found partially under the bed with a bruise on the head. Despite this, there was no documented assessment at the time of this fall. A neuro check form was only initiated after a third fall later that day. The nurse involved in the 8:00 AM fall did not document any assessments and was unavailable for an interview as they no longer worked at the facility. The Director of Nursing confirmed that the staff was aware of the falls but failed to document them properly at the time.
Failure to Document Resident Falls Accurately
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for a resident with dementia, manic depression, and a history of fractures due to falls. On the date of the incident, the resident experienced multiple falls, which were not accurately documented by the nursing staff. Initially, a fall was documented at 4:16 AM, where the resident was found in the hallway and assisted back to bed without any noted injuries. However, later that day, the resident exhibited signs of confusion, lethargy, and an unsteady gait, leading to a hospital transfer where rib fractures and a lacerated spleen were diagnosed. Further investigation revealed that additional falls occurred on the same day, including one where the resident was found partially under the bed with a bruise on the head, and another near the elevator where the resident's knee touched the floor despite attempts to prevent the fall. These incidents were not documented at the time they occurred, as the involved nurses assumed others would document them. This lack of documentation was acknowledged by the facility's Director of Nursing, who confirmed that the staff was aware of the falls but failed to record them promptly.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 58 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Charlottesville | 0.8 mi | ★★★★★ | 0 | 0 |
| Colonnades Health Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 1 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Peace Inc | 1.1 mi | ★★★★★ | 15 | 0 |
| Charlottesville Health & Rehabilitation Center | 1.3 mi | ★★★★★ | 7 | 0 |
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