Monroe Community Hospital

In the surveyor’s words

From the most serious findings on record at Monroe Community Hospital, in the surveyor’s own words.

• Immediate jeopardy, widespreadF684Oct 24, 2025

  Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 had no documented bowel movement from 09/24/2025 through 10/03/2025 and there was no documented evidence any as needed medications for constipation were administered. […]

• Immediate jeopardy, isolatedF686Oct 24, 2025

  Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents (Resident #1) reviewed. Specifically, the facility failed to assess, treat and prevent deterioration of Resident #1's sacral pressure ulcer from 08/30/2025 through 09/22/2025 which resulted in severe pain to the wound and the wound required sharp debridement during a hospitalization. […]

• Immediate jeopardy, isolatedF689Jul 15, 2021

  Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY 844), completed on 7/15/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for one of two residents reviewed. Specifically, Resident #243 was assessed for safe smoking on 11/30/20, 3/8/21 and again 5/28/21 and determined to be unsafe to smoke unattended. On 4/23/21 Resident #243 went outside unsupervised, obtained cigarettes from another resident, asked another resident to help light the cigarette and Resident #243's hair caught on fire. The fire was put out by another resident and Resident #243 sustained a partial thickness burn to the forehead. […]

• Actual harm, isolatedF686Sep 12, 2025

  Based on observations, interviews and record review conducted during an Abbreviated Survey (Complaint #: NY00368800/Intake ID: 466508) from 08/26/2025 to 09/12/2025, the facility failed to ensure residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for one (1) of three (3) residents (Resident #8) reviewed. Specifically, the facility failed to ensure Resident #8's specialty mattress was in place from 01/04/2025 to 01/10/2025, and the resident was later found to have a stage two (2) (partial-thickness skin loss) and stage three (3) (full-thickness skin loss) pressure ulcer to their buttocks. […]

• No harm, potential for more than minimal, patternF655Dec 20, 2024

  Based on interviews and record review conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, for 11 (Residents #24, #35, #136, #158, #246, #257, #357, #374, #375, # 378, #380) of 11 residents reviewed, the facility did not ensure that the baseline care plan (care plan developed within 48 hours of admission that includes the minimum healthcare information necessary to properly care of the immediate needs of the resident) was completed within the required time frame and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Residents #35, #136, and #257, the facility could not provide evidence that a baseline care plan was developed within 48 hours of the residents' admission. […]