Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Regency Care Center At Monroe during CMS and state inspections, most recent first.
The facility did not ensure that the Dietary Manager had completed the required accredited program in nutrition or dietetics, and the Registered Dietitian was not present full-time, resulting in noncompliance with staffing regulations for food and nutrition services.
The facility did not have an effective system to address and resolve resident grievances, as evidenced by repeated concerns voiced during resident council meetings and a resident's report of missing clothing that were not documented or followed up according to policy. Staff interviews revealed inconsistent understanding and use of the grievance process, and the facility's grievance log showed no entries for these issues, resulting in unresolved complaints and lack of communication with residents about the status of their concerns.
Staff failed to disinfect mechanical lifts between resident uses, did not consistently use gloves when handling garbage in rooms with enhanced barrier precautions, and neglected to wear required gowns or perform proper hand hygiene during high-contact resident care. These lapses occurred despite staff awareness of facility policies and posted instructions.
The facility did not ensure accurate MDS assessments for three residents, resulting in incorrect documentation of fall history and diagnoses. Two residents' MDS assessments failed to reflect recent falls, and a third resident's diagnosis was inaccurately recorded due to a likely transcription error. Staff did not adequately review EHRs or verify diagnoses when completing the assessments.
A resident with a history of pelvic fracture, chronic pain, and spinal stenosis, who required assistance with bathing, did not receive scheduled showers as documented, resulting in a ten-day period without a shower and only two showers provided in a month. Staff interviews confirmed that the resident was not given showers according to the facility's schedule, and there was no documentation of refusals during this time.
A resident with a history of cataracts and diabetes reported difficulty seeing and had not received an optometry exam since receiving new glasses several years prior, despite a recommendation for annual follow-up. Staff were unaware of the resident's vision complaints, and the process for scheduling optometry visits was not effectively implemented, resulting in a lack of timely vision care.
A resident with malnutrition and poor oral intake was not offered meal substitutes or supplements as required by facility policy, and staff failed to encourage eating or accurately document meal consumption. The resident's food preferences were not recorded, and recommendations for protein shakes were not followed, resulting in inadequate nutritional support.
A resident receiving hemodialysis had inconsistent and inaccurate documentation on dialysis communication forms, with nurses recording assessments for a fistula (bruit and thrill) despite the resident having a femoral tunneled catheter. The care plan also misidentified the access site, and staff interviews revealed confusion about the type and location of the dialysis access. These failures resulted in incomplete and inaccurate coordination of care.
A resident with ADHD and bipolar disorder did not receive necessary behavioral health care, as a recommended psychiatric evaluation of their medications was not completed or acknowledged by staff or a physician. Documentation showed inconsistent follow-up on mental health service referrals, and staff interviews revealed limited access to mental health resources and delays in service initiation.
A resident with a chronic abdominal wall abscess continued to receive weekly Fluconazole without documented clinical justification. Staff and pharmacy reviews did not address the ongoing need for the medication, and provider notes lacked explanation for its continued use, resulting in administration of a potentially unnecessary drug.
A resident receiving hospice care did not have hospice nurse or home health aide visit documentation available in the facility's records. Staff confirmed that hospice staff documented in their own system, which was not accessible to facility staff, and there was no consistent process to ensure these notes were received or uploaded into the facility's EHR.
An emergency cart was found with an unlocked, soiled sharps container containing five syringes. An LPN was unsure why the sharps container was present on the cart and stated that sharps are usually disposed of in the biohazard room. The DON confirmed that locked sharps containers are normally used for sharp disposal.
Noncompliance with Dietary Manager Credential Requirements
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required credentials to oversee food and nutrition services in the absence of a full-time Registered Dietitian. The Dietary Manager had been in the role for nearly a year but had not yet completed an accredited academic program in nutrition or dietetics, and only held a ServSafe Food Protection Manager Certification, which does not meet the regulatory requirements. The Registered Dietitian employed by the facility worked 32 hours per week, splitting time between this facility and another, and was only physically present one day per week, with remote work on another day. The Administrator confirmed that the Dietary Manager was still in the process of obtaining the necessary certification and that the Registered Dietitian was shared between facilities. This situation resulted in dietary services being provided by staff without the required competencies and credentials as specified by regulations.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to establish and maintain an effective system for addressing and resolving resident grievances, as required by policy. Review of resident council (RC) meeting minutes over a six-month period revealed that residents consistently voiced concerns, such as overflowing trash containers, insufficient shower aides, excessive nighttime noise, untimely bed making, and issues with laundry detergent causing itching. Despite these recurring complaints, there was no evidence that the facility documented these grievances or provided follow-up or resolution to the residents. Residents interviewed confirmed that while previous meeting minutes were reviewed, there was no follow-up or notification regarding the status or resolution of their concerns. Additionally, the facility did not follow its grievance process for a resident who reported missing personal clothing. The resident stated they had informed aides and laundry staff about the missing pants, but no grievance form was completed, and the issue remained unresolved. Staff interviews revealed inconsistent understanding and application of the grievance process, with some staff indicating that grievance forms were primarily used for family complaints or only when residents were visibly upset. The designated grievance official, the Social Services Director, reported not receiving any grievance forms related to the missing clothing or other concerns raised in RC meetings. A review of the facility's grievance log showed no documented grievances from the RC meetings or the resident with missing clothing during the review period. The facility's policy requires that all grievances be documented, investigated, and followed up with written decisions, but this process was not followed. As a result, residents repeatedly reported the same issues without resolution, and their concerns were not formally addressed or tracked according to policy.
Failure to Follow Infection Control Protocols for Equipment, PPE, and Resident Care
Penalty
Summary
Staff on the Cascade unit failed to follow infection prevention and control protocols regarding equipment sanitation, garbage handling, and use of personal protective equipment (PPE). Multiple staff members were observed not disinfecting mechanical lifts after use between residents, despite facility policy requiring the use of disinfectant wipes or sprays on non-critical items between uses. Staff interviews confirmed knowledge of the requirement but revealed lapses in practice, with staff either forgetting or assuming another staff member would perform the disinfection. Additionally, a staff member was observed leaving a room with enhanced barrier precautions (EBP) signage and not cleaning the lift, even though cleaning supplies were readily available. In another instance, a staff member was observed handling garbage in a resident room with EBP signage without wearing gloves, using bare hands to push down the garbage before removing the bag. The staff member acknowledged not wearing gloves and cited being told not to wear gloves in the hallway, but no further explanation was provided. This action was inconsistent with infection control standards, especially in rooms requiring enhanced precautions. Deficiencies were also noted in the use of PPE during resident care. For a resident with chronic wounds and EBP in place, staff provided high-contact care, including pericare, dressing, and transferring, while only wearing gloves and not gowns as required by the posted EBP instructions. Both staff involved acknowledged after reading the sign that gowns should have been worn but stated they forgot. Additionally, during pericare for another resident, staff failed to change gloves and perform hand hygiene after cleaning the perineal area and before applying a clean brief, and touched clean items and the environment with contaminated gloves. Staff interviews confirmed awareness of the correct procedures but admitted to not following them during the observed care.
Inaccurate MDS Assessments for Falls and Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For two residents, the MDS assessments did not accurately reflect their fall history or incidents of falls that occurred both prior to and after admission. Interviews with the residents confirmed they had experienced falls, and electronic health records documented these incidents. However, the admission MDS for both residents indicated no falls in the relevant timeframes, and the care area assessment (CAA) for falls was not triggered as a result. Staff interviews revealed that the MDS Coordinator did not review the residents' electronic health records when completing the assessments, leading to inaccurate documentation. For another resident, the quarterly MDS assessment listed a diagnosis of schizophrenia and did not indicate the use of antipsychotic medication. However, a review of the resident's diagnosis list showed that schizoaffective disorder - bipolar type had been added previously. Staff, including the MDS Coordinator and Resident Care Managers, were unable to provide documentation supporting this diagnosis and later determined it was likely a transcription error, with the wrong diagnosis code selected during data entry. These inaccuracies in the MDS assessments resulted from a lack of proper review and verification of resident records and diagnoses.
Failure to Provide Scheduled Showers for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's ability to perform activities of daily living (ADLs), specifically bathing/showering, did not diminish without a medical reason. A resident admitted with a history of pelvic fracture, chronic pain, and spinal stenosis required supervision or touch assistance from one person for bathing. Despite this, documentation showed that the resident received only two showers in November, with a gap of ten days without a shower from admission onward. The resident reported going almost two weeks without a shower and expressed a desire for more frequent bathing. Staff interviews revealed that residents are scheduled for showers at least once a week, and refusals are documented after multiple encouragement attempts. However, the resident in question was not provided showers according to this schedule, and there was no documentation of refusals during the period in question. The Director of Nursing confirmed that residents are placed on a shower schedule and that adjustments are made for special requests, but could not provide additional documentation to show showers were offered or provided to the resident after admission.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to provide proper treatment to maintain vision for a resident with a history of cataracts and diabetes mellitus type 2. The resident, who was cognitively intact and wore glasses, expressed a desire to have their eyes checked and reported difficulty reading the television even with their eyeglasses. The last documented optometry visit for the resident was in 2021, despite a recommendation for a follow-up in one year. There was no evidence in the medical record of any subsequent optometry visits or updated assessments, and the resident could not recall the last time they had an eye exam. Staff interviews revealed that the process for scheduling optometry visits relied on resident or family requests, care conference discussions, or staff observations. However, the optometrist only visited when there were at least six residents on the list, and the resident in question had not been added to the list despite reporting vision issues. Nursing and care staff were unaware of the resident's complaints, and documentation from a recent care conference left the section on visual appliances blank, with 'not applicable' checked. This lack of follow-up and communication resulted in the resident not receiving timely vision care as recommended.
Failure to Provide Adequate Nutrition and Accurate Documentation
Penalty
Summary
The facility failed to implement effective interventions to maintain adequate nutrition for a resident identified as being at risk for nutritional problems and diagnosed with malnutrition. Despite the facility's policy requiring meal substitutes to be offered when a resident consumes less than 50% of a meal, observations showed that staff did not encourage the resident to eat or offer substitutes when intake was low. The resident consistently consumed less than half of their meals, expressed dissatisfaction with the food, and reported a lack of appetite due to loss of taste and smell. Collateral contacts confirmed the resident's poor intake and noted that staff did not offer meal substitutes or protein drinks as recommended. Documentation in the resident's records was found to be inaccurate, with staff recording higher meal consumption than what was observed. The care plan and provider notes indicated the need for meal substitutes and supplements, but these interventions were not provided. The registered dietician relied on inaccurate aide documentation and did not interview the resident or family regarding meal intake history. There was also no documentation of the resident's food preferences in the electronic health record until prompted by the surveyor, and recommendations from a hospital dietitian for protein shakes were not followed.
Inaccurate Dialysis Documentation and Care Planning
Penalty
Summary
The facility failed to provide consistent, complete, and accurate assessments for a resident receiving hemodialysis, as evidenced by discrepancies in documentation and care planning. Specifically, the dialysis communication forms completed by licensed nurses repeatedly documented the presence of bruit and thrill, which are indicators associated with a fistula, despite the resident having a right femoral tunneled catheter line and not a fistula. Interviews with staff revealed confusion regarding the type and location of the resident's dialysis access site, with some staff incorrectly identifying it as a port or an upper chest central line, while the actual site was a right femoral tunneled catheter. The care plan also inaccurately described the access site, and staff relied on incorrect information from the communication board and provider orders. The resident, admitted with end stage renal disease and receiving regular hemodialysis, had their access site managed exclusively by the dialysis center, with facility staff only reinforcing the dressing. Despite this, the facility's documentation and care planning did not accurately reflect the resident's current access site or the appropriate assessments, leading to inconsistent communication between the facility and the dialysis center. These documentation errors and lack of accurate care planning were confirmed through interviews and record reviews, highlighting a failure to ensure safe and appropriate dialysis care and services for the resident.
Failure to Provide Behavioral Health Services and Medication Review Follow-Up
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with diagnoses including attention-deficit hyperactivity disorder and bipolar disorder. A monthly medication review recommended a psychiatric evaluation of the resident's medications as a contributing factor to falls, but this review was neither signed by the physician nor acknowledged by facility staff. Additionally, there was a lack of documentation regarding the initiation or follow-up of mental health services for the resident, with only sporadic references to referrals and no evidence of consistent behavioral health interventions. Interviews with facility staff revealed that there were limited resources for mental health services, and several residents were waiting to start services with a newly contracted mental health provider. Staff also indicated that previous attempts to connect residents with local mental health organizations were hindered by logistical challenges and excessive wait times. The social services department and medical director were involved in discussing and reviewing behavioral health needs, but there was no documentation that these services were provided or that recommendations were acted upon for the resident in question.
Failure to Evaluate Ongoing Need for Antifungal Medication
Penalty
Summary
A deficiency was identified when a resident with a history of chronic abdominal wall abscess was found to have an active order for Fluconazole 200 mg weekly, which had been in place since June 2024. Review of the resident's medical record and monthly Medication Administration Records confirmed ongoing administration of the antifungal medication, but there was no documentation indicating the clinical rationale for its continued use. Pharmacy medication regimen reviews from December 2024 onward did not address the necessity of the Fluconazole, and provider progress notes did not document a reason for maintaining the order. Interviews with nursing staff and the Director of Nursing Services revealed uncertainty regarding the indication for the medication, with staff speculating it might be for prophylactic use but unable to provide supporting documentation. The order was listed as being for "infection," but this was not substantiated in the resident's records. The lack of documented evaluation or justification for the ongoing use of Fluconazole resulted in the resident receiving a potentially unnecessary medication.
Failure to Maintain Accessible and Complete Hospice Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for a resident receiving hospice services. Specifically, the resident was enrolled in hospice care, with a plan of care indicating that a hospice nurse and home health aide were to visit multiple times per week. However, a review of the resident's electronic health record (EHR) revealed no documentation of hospice nurse visits after a certain date, and the binder maintained for hospice documentation contained no records of visits by either the hospice nurse or home health aide. Multiple staff interviews confirmed that hospice staff documented in their own system, to which facility staff had no access, and that there was no consistent process for ensuring hospice visit notes were received or uploaded into the facility's EHR. Staff members, including RNs and the Director of Nursing Services, acknowledged that communication with hospice staff occurred verbally or by phone, but written documentation of hospice visits and care was not available in the facility's records. The hospice nurse and home health aide documented their visits and care activities in the hospice agency's system, but these records were not routinely shared with or accessible to facility staff. As a result, the facility did not have the required hospice documentation in the resident's medical record, as required by professional standards and regulations.
Unsecured and Soiled Sharps Container Found on Emergency Cart
Penalty
Summary
A deficiency was identified when an emergency cart located outside the Cascade Residential Unit Nurses station was observed to have an unlocked sharps container on its lower shelf. The sharps container was found to be soiled with unidentifiable brown matter on the top cover and contained five syringes inside. During interviews, an LPN stated that the cart was used as an emergency kit and suctioning cart, and expressed uncertainty about the purpose of the sharps container being present on the cart. The LPN also indicated that the usual process for disposing of sharps involved placing them in a disposable box in the biohazard room. The DON confirmed that locked sharps containers are typically available on each nurse's cart for sharp disposal.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Snohomish Health And Rehabilitation Of Cascadia | 6.9 mi | ★★★★★ | 39 | 1 |
| Bethany At Silver Lake | 10.1 mi | ★★★★★ | 10 | 0 |
| Madison Post Acute | 11.4 mi | ★★★★★ | 1 | 0 |
| Corwin Center At Emerald Heights | 12 mi | ★★★★★ | 0 | 0 |
| Bothell Health Care | 12.3 mi | ★★★★★ | 2 | 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.