Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Monroe Health Services during CMS and state inspections, most recent first.
Food storage and sanitation practices were not maintained according to professional standards. Surveyors observed opened refrigerated items that were not dated, frozen foods that were unlabeled or improperly sealed, freezer-burned chicken, a dirty stand mixer, and an unclean ice bin. During lunch service, a staff member sanitized a food thermometer with an alcohol wipe between items but did not allow it to dry before using it on the next food item, increasing the risk of cross-contamination.
A resident with intact cognition was moved from a private room on a hallway near therapy after the facility redesignated that area for rehab use and told residents they would have to pay a daily private-room fee to stay. The resident said she did not want to move, but was transferred anyway, and staff confirmed the change was intended to save therapy staff time and steps by keeping rehab residents closer to the therapy gym.
A resident with a history of atrial fibrillation, heart disease, and a femur fracture had a resting HR above the facility’s reporting threshold, but the RN did not notify the provider immediately and waited about 3.5 hours before calling the on-call NP. The resident’s HR remained elevated on reassessment, and the resident was later sent to the ER and admitted to the hospital for PE and UTI. Interviews confirmed staff expected abnormal vital signs to be reported right away.
A resident with CHF and ESRD on dialysis had physician orders for daily weights and provider notification for significant weight gain, but staff missed multiple ordered weights and did not document physician notification despite several large weight increases. The DON stated the resident should have been re-weighed and the provider notified when the gains were identified, especially given the resident’s fluid overload risk and dialysis status.
A resident's cell phone was misappropriated by a housekeeper, who was later terminated based on evidence, although the theft could not be conclusively proven. The resident, who was cognitively intact, reported seeing the housekeeper take the phone. The facility's policy on abuse prevention was not effectively implemented, and the contracted housekeeping company failed to provide adequate follow-up training to its staff.
A resident with Chronic Kidney Disease Stage 4 had critical lab results that were not communicated to a provider. The facility's process for handling lab results broke down, as the Nurse Practitioner was on vacation and the on-call provider was not notified. Staff interviews revealed no specific timeframe for checking lab results, and the Director of Nursing expected follow-up that did not occur.
A resident with a history of osteoporosis was found with a bruise on her arm, which was not reported to the State Agency within the required timeframe. The facility's policy requires immediate reporting of such incidents, but the Nursing Home Administrator and Director of Nursing delayed reporting until the resident's family alleged abuse. An x-ray later revealed a fracture, highlighting a deficiency in the facility's reporting procedures.
A facility failed to create a comprehensive care plan for a resident prescribed Melatonin for insomnia. The care plan did not include the medication, and there was no sleep assessment or tracking to evaluate its effectiveness. Interviews with facility staff confirmed the absence of necessary assessments and monitoring.
A resident with essential hypertension had physician orders for daily weights over seven days, but the facility failed to document weights on three days. Despite this, the MAR was signed for all days, indicating a discrepancy. Interviews with staff confirmed that weights should be documented in the PCC system daily, but this was not done, leading to a failure in following physician orders.
The facility failed to provide adequate wound care and post-fall assessments for residents. Two residents did not receive documented wound care as per orders, and a resident who fell was moved without a complete RN assessment, leading to a missed fracture diagnosis.
A resident with a stage 3 pressure wound on the left calf did not receive prescribed treatment due to a failure to transcribe the wound care order onto the Treatment Administration Record (TAR). The treatment, which included the application of Leptospermum honey and a secondary dressing, was not completed on multiple days. The Director of Nursing confirmed the lapse in documentation and treatment, acknowledging that if it was not documented, it was not done. Despite this, the resident's wound did not worsen during the period of non-compliance.
Two residents experienced medication administration errors, resulting in a 5.88% error rate. An RN failed to assess vital signs before administering Lisinopril, and an LPN gave Omeprazole with breakfast instead of one hour prior, both against physician orders.
A resident with severe cognitive impairment and multiple falls had inaccurate fall risk assessments in their medical records. Despite being on medications that increased fall risk, assessments often indicated a low risk. Interviews with staff revealed inconsistencies in the assessment process, and the DON acknowledged the inaccuracies.
A resident was given an antibiotic for a suspected UTI before urine culture results were finalized. The culture showed mixed flora with no specific bacteria, yet the antibiotic treatment continued without consulting the physician or recollecting a sample. The ADON/IP relied on the CFU/ml result, and the DON expected physician consultation, highlighting a failure in the facility's antibiotic stewardship program.
Food Storage, Equipment Cleanliness, and Thermometer Handling Deficiencies
Penalty
Summary
Food was not stored, prepared, and handled in accordance with professional standards for food service safety. During the initial kitchen tour, surveyors observed opened food items in refrigerators and coolers that were not dated, including lettuce, egg patties, and pizza crusts. In the freezers, surveyors observed chicken pieces with no date or label and visible freezer burn, puff pastry and cookies with no date or label, and a package of polish sausages stored in a bag with a hole. Surveyors also observed the facility's industrial stand mixer covered but with dried white splatters near the mixing blade, and an unclean ice bin. The facility policy stated that food would be covered for storage, food with an abnormal appearance would be discarded, and all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. During lunch service, surveyors observed a staff member taking food temperatures and sanitizing the thermometer with an alcohol wipe between items, but not allowing it to dry at least 10 seconds before inserting it into the next food item. Surveyors observed the thermometer being placed into cooked cauliflower, noodles, pureed and ground chicken, hamburger patty, chicken breasts, hot dog, pureed cauliflower, mashed potatoes, and tomato soup. The NHA and Kitchen Manager were interviewed and stated they would expect the food and ice machine to be properly stored and kept clean; the NHA also stated the ice machine should be clean and free of mold.
Resident Room Transfer Without Right to Refuse
Penalty
Summary
The facility did not protect a resident’s right to refuse a room transfer when the move was made solely for staff convenience. Surveyors found that the facility planned to redesignate the 400 hall for therapy residents so therapy staff could save time and steps by keeping residents closer to the therapy department. Residents on the 400 hall were sent letters stating they would be moved to the 100 or 200 halls unless they chose to pay $390 per day for a private room, and the letters said the 400 hall would be reserved for therapy patients. One resident, R41, had intact cognition with a BIMS score of 15 out of 15 and had lived in a room on the 400 hall since 11/21/22. R41 told surveyors she did not want to move, but was told she would have to pay the private room fee if she stayed. She was moved to the 100 hall on 9/11/25. R41 stated she was the only resident on the hallway who had to move and that she was actively participating in physical therapy at the time. The social worker and administrator confirmed the purpose of the room changes was to return the 400 wing to a rehabilitation wing because it was closer to therapy. The administrator stated the facility told R41 she had an increase in care and needed closer observation, but also acknowledged that R41 had been moved to a Hoyer lift and no longer used it. The administrator further stated the facility does not have specific beds licensed for Medicare and Medicaid residents and acknowledged concern about the room transfers.
Delayed Physician Notification for Elevated Heart Rate
Penalty
Summary
The facility failed to immediately notify and consult the resident’s physician when there was a change in condition for one resident. The facility’s policy required immediate notification for a marked change in usual symptoms and signs, including a resting pulse greater than 100. Resident R46 was admitted with diagnoses including displaced fracture of the greater trochanter of the right femur, atherosclerotic heart disease, and longstanding persistent atrial fibrillation, and had a BIMS score of 13 indicating normal cognitive function. On 6/23/2025, nursing documentation showed R46’s heart rate was 135 at 9:33 AM, with an apical rate of 130 after assessment, and remained 130 on reassessment at 12:38 PM. The provider was not updated until 1:05 PM, approximately 3.5 hours after the elevated pulse was first noted. The on-call provider then directed that the resident be sent to the ER for further workup, and the resident was later admitted to the hospital for PE and UTI. During interviews, RN C stated she waited because she thought metoprolol might help first, even though she acknowledged the policy required immediate reporting of an abnormal vital sign. NP F stated she would expect the RN to call immediately for an abnormal heart rate, and the DON stated nurses should call the doctor immediately after rechecking to confirm the reading.
Failure to Monitor Daily Weights and Report Significant Weight Gain
Penalty
Summary
The facility failed to maintain acceptable nutritional status monitoring and failed to consult the resident’s physician regarding weight gain for one resident with congestive heart failure and stage 5 renal disease who was dependent on dialysis. The resident had physician orders for daily weights and for provider notification if there was a 3-pound gain in one day or 5 pounds in one week, but the facility did not obtain daily weights on numerous dates between 10/1/25 and 12/2/25. The record also showed no re-weight was obtained between 9/13/25 and 12/2/25 to confirm whether a documented weight was accurate. The resident’s record showed multiple weight increases, including an 11.5-pound gain in one day, a 4.8-pound gain in one day, a 14-pound gain over four days, a 14-pound gain in one day on readmission, and an 18.7-pound gain over five days. Review of the resident’s progress notes, vital signs, and MAR from 10/1/25 through 12/2/25 showed no documentation that the physician was made aware of the resident’s weight gain. The resident’s care plan identified edema/excess fluid volume related to cardiac disease and renal disease, with interventions to report signs and symptoms of fluid overload such as weight gain, abnormal lung sounds, and extremity swelling. During interview, the DON stated staff should obtain daily weights, that the resident should be weighed before leaving for dialysis, and that weight gains such as those reviewed should have been re-weighed and reported to the physician. The DON stated the resident’s 11.5-pound gain in one day, 4.8-pound gain in one day, 14-pound gain, and 18.7-pound gain should all have been addressed, assessed, and reported, and acknowledged that the resident’s order clearly required provider notification for a 3-pound gain in one day. The DON also stated the resident’s weight gain was concerning because of heart failure and fluid retention, and that staff needed to continue monitoring the resident.
Misappropriation of Resident's Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically a cell phone, by a housekeeper. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident reported seeing a housekeeper take her phone and put it in her pocket. The phone was later found in the car of another housekeeper, with whom the accused housekeeper was carpooling. Despite the resident's clear account of the event, the facility and police were unable to substantiate the theft, but the housekeeper was terminated based on the evidence. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the misappropriation of the resident's property. The facility's response included suspending the housekeeper and involving the police, but the investigation did not conclusively prove the theft. Interviews with staff and the resident confirmed the resident's account, but the facility's contracted housekeeping company did not provide adequate follow-up training or reeducation on abuse prevention to its staff. The incident highlighted a gap in the facility's oversight of contracted staff, as the housekeeping company was responsible for background checks and training. The facility's administration and nursing staff were involved in the investigation, but there was a lack of coordination with the contracted housekeeping company to ensure all staff received necessary abuse prevention training. This deficiency in communication and training contributed to the failure to protect the resident's property effectively.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, as evidenced by the lack of notification regarding abnormal lab results for a resident. The resident, who was admitted with multiple diagnoses including Chronic Kidney Disease Stage 4, had lab results showing significantly elevated Blood Urea Nitrogen (BUN) and Creatinine levels, and a low Glomerular Filtration Rate (GFR). Despite these critical findings, there was no evidence that the lab results were communicated to or reviewed by a provider. Interviews with facility staff revealed a breakdown in the process of handling lab results. The Nurse Practitioner who ordered the labs was on vacation, and the facility did not notify the on-call provider of the results. The Director of Nursing and Unit Manager indicated that there was no specific timeframe for checking lab results, and the Unit Manager did not recall the resident's labs. The Director of Nursing expected staff to follow up with the provider once lab results were received, but this did not occur, leading to a failure in addressing the resident's critical condition in a timely manner.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime in accordance with section 1150B of the Act, specifically regarding an injury of unknown origin for a resident, identified as R10. R10, who has a medical history including Alzheimer's disease, osteoporosis, dementia, generalized anxiety disorder, and major depressive disorder, was found with a bruise on her upper right arm on 7/7/24. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the State Agency until 7/11/24, which is beyond the required timeframe. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but not later than 24 hours if the events do not involve abuse or result in serious bodily injury. However, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not adhere to this policy. The NHA reported the incident only after R10's family alleged abuse, despite being aware of the injury on 7/7/24. The DON initially assessed the bruise as small and not of unknown origin, attributing it to changing R10's clothing, but later acknowledged the bruise had grown significantly by 7/8/24. The delay in reporting was further compounded by the facility's decision to pursue an x-ray only after the family insisted, which revealed a fracture with displacement of the humeral head. The NHA and DON both acknowledged the reporting delay, with the DON stating that the injury should have been reported immediately, especially when physical harm is alleged. The facility's failure to report the injury within the required timeframe constitutes a deficiency in their reporting procedures.
Failure to Develop Comprehensive Care Plan for Resident on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R35, who was prescribed Melatonin for insomnia. Despite the resident's cognitive intactness and existing diagnoses of weakness, obstructive sleep apnea, and depression, the care plan did not include any mention of Melatonin use. The facility's policy mandates that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not adhered to in R35's case. The care plan, dated February 2024, only mentioned sleep cycle issues related to depression without addressing the Melatonin prescription. Additionally, there was no sleep assessment or sleep tracking documented for R35, which is crucial to evaluate the effectiveness of the Melatonin treatment. The Medication Administration Record from May to July 2024 lacked any documentation of sleep tracking or the effectiveness of the medication. Interviews with the Vice President of Success and the Director of Nursing revealed that the facility did not conduct a sleep assessment for R35, and the Director of Nursing acknowledged the necessity of sleep monitoring for residents on sleep medication.
Failure to Document Daily Weights as Ordered
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to physician orders for daily weight monitoring of a resident, identified as R40, who was admitted with essential hypertension. The physician had ordered daily weights for seven days, but the facility did not complete this task on three of those days. Despite the absence of weight documentation for these days, the Medication Administration Record (MAR) was signed for all seven days, indicating a discrepancy between recorded actions and actual practice. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that weights should be documented in the Point Click Care (PCC) system on the same day they are taken. The DON confirmed that the facility's policy requires weights to be documented in PCC to ensure that any significant weight changes are communicated to the physician. However, the lack of documentation for three days meant that the facility did not follow the physician's orders, and staff would not have been aware of any necessary updates to the physician regarding weight changes.
Deficiencies in Wound Care and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For two residents with non-pressure wounds, there were multiple instances where wound care treatments were not documented as completed on the Treatment Administration Record (TAR). One resident, who was cognitively intact, had specific orders from a wound doctor that were not transcribed onto the TAR or completed, leading to gaps in wound care. Another resident had similar issues with wound care treatments not being documented, indicating they were not completed as per the orders. Additionally, the facility did not conduct a thorough assessment following a fall for a resident who later was found to have a fracture. The resident, who had a history of hemiplegia and osteoporosis, fell while reaching for a cupcake. The resident was moved from the floor to a wheelchair and later to a bed without a complete assessment by a Registered Nurse (RN). The documentation provided was inconsistent and lacked a full physical assessment, which is required after a fall. Interviews with facility staff, including the Director of Nursing (DON) and the Infection Preventionist/Wound Nurse, revealed that there were lapses in the process of entering and completing wound care orders. The DON confirmed that if treatments are not documented, they are considered not done. Furthermore, the RN involved in the post-fall incident admitted to not completing a full assessment and moving the resident without proper evaluation, which is against the facility's policy for fall management.
Failure to Administer Pressure Ulcer Treatment as Ordered
Penalty
Summary
The facility failed to implement professional standards of practice for pressure ulcer care for a resident, identified as R147, who was reviewed for pressure injuries. The resident, who was admitted with a stage 3 pressure wound on the left calf, had a treatment plan prescribed by a wound doctor, which included the application of Leptospermum honey and a secondary dressing of gauze island with a border, to be applied once daily for 23 days. However, this order was not transcribed onto the resident's Treatment Administration Record (TAR) and was not completed as ordered on multiple days. The facility's policy requires that new medication orders be documented in the resident's medical record and entered into the TAR. Despite this, the treatment for R147's pressure injury was not documented or completed from 5/21/24 to 6/6/24. The Director of Nursing (DON) confirmed that the orders were not on the TAR during this period and acknowledged that if it was not documented, it was not done. Although the resident's wound did not worsen during the time the treatment was not completed, the facility did not adhere to its policy of administering treatments as ordered and monitoring for effectiveness.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 5.88%, exceeding the acceptable threshold of 5%. This was based on two errors observed during a medication pass task involving two residents. The first error involved a registered nurse (RN) who administered Lisinopril to a resident without assessing the resident's vital signs, as required by the physician's orders. The orders specified that the medication should be held if the resident's systolic blood pressure was below 100, diastolic blood pressure was below 60, or heart rate was below 60. The RN admitted to not taking the vital signs on the day of the observation, despite being aware of the hold parameters. The second error involved a licensed practical nurse (LPN) who administered Omeprazole to another resident with breakfast, contrary to the physician's orders that specified the medication should be given one hour before breakfast. The LPN acknowledged the error during an interview with the surveyor. The Director of Nursing confirmed that medications should be administered as ordered and recognized both instances as medication errors. The facility's policy on medication administration was not adhered to in these cases, leading to the identified deficiencies.
Inaccurate Fall Risk Assessments for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as R39, who was at high risk for falls. R39's medical records contained inaccurate fall risk assessments following five falls within the facility over a three-month period. The resident was admitted with diagnoses including encephalopathy, vascular dementia, and polyneuropathy, and was severely cognitively impaired with a BIMS score of 3 out of 15. Despite these conditions and a history of falls, the fall risk assessments inaccurately reflected the resident's fall risk level, often indicating a low risk when the resident had multiple falls and was on medications that increased fall risk. The post-fall assessments for R39 were inconsistent and did not accurately document the number of falls or the medications that contributed to the fall risk. For instance, one assessment indicated no falls in the past 30 days and 1-2 falls in the past 90 days, when the resident had actually experienced three falls. Additionally, the assessments failed to account for medications such as a diuretic, laxative, psychotropic medication, and antidepressant, which were known to increase fall risk. This lack of accurate documentation and assessment led to an underestimation of the resident's fall risk. Interviews with facility staff, including an LPN, RN, and the DON, revealed a lack of consistency in the fall risk assessment process. Staff acknowledged that recent falls and certain medications should increase a resident's fall risk, yet the assessments did not reflect this understanding. The DON admitted that the fall risk assessments for R39 were not accurate and should have been completed correctly. This deficiency in maintaining accurate medical records and assessments compromised the facility's ability to effectively manage and mitigate the resident's fall risk.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program, which is part of its infection prevention and control program, by not following antibiotic use protocols and failing to monitor antibiotic use effectively. A resident, identified as R2, was administered an antibiotic, cefuroxime, for a suspected urinary tract infection (UTI) before the urine culture results were finalized. The urine culture results, which were available the day after the antibiotic was started, indicated mixed flora with no specific bacteria isolated, and suggested recollection if clinically indicated. Despite this, the antibiotic treatment continued without further consultation with the physician or recollection of a urine sample. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) were interviewed and acknowledged the oversight. The ADON/IP admitted to relying solely on the >100,000 CFU/ml result for treatment, while the DON expressed that the expectation would have been to contact the physician to discuss the results and consider recollecting a urine sample. The facility's failure to reassess the need for antibiotics after receiving the culture results, which did not confirm a specific infection, led to the continuation of unnecessary antibiotic treatment for R2.
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 140 citations issued within 25 miles in the last 12 months — including the 5 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 Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Nursing Home | 0.9 mi | ★★★★★ | 18 | 0 |
| New Glarus Home | 14.6 mi | ★★★★★ | 18 | 1 |
| Serenity Estates Of Lena | 19.2 mi | ★★★★★ | 3 | 0 |
| Medina Nursing Center | 19.5 mi | ★★★★★ | 8 | 1 |
| Evansville Manor Nursing And Rehab, Llc | 20.1 mi | ★★★★★ | 29 | 3 |
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