Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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What surveyors actually found near you
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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 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 | — | 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 August 2026) and official state health department websites.