Monroe Community Hospital

Inspectors wroteBased 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. Resident #1 was hospitalized on [DATE] and found to have severe rectal stool burden (excessive amount of stool in the colon or rectum) requiring manual disimpaction (a procedure used to remove stool from the rectum) and stercoral colitis (an inflammatory condition of the large bowel caused by substantial stool burden). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This resulted in actual harm to Resident #8 that is not Immediate Jeopardy.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00356480) from 12/16/2024 to 12/20/2024, for two (Residents #27 and #640) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a dignified manner. Specifically, Resident #27 could be heard moaning from the hallway with their call light on. Multiple staff members were observed walking by the resident's room without answering the call light or turned the call light off without addressing the resident's concerns or requests. Resident #640 had their call light on for an extended period of time and multiple staff went in the resident's room and turned the call light off without addressing the resident's concerns. This was evidence by the following: 1. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, the facility did not ensure that the medical team was notified when there was a significant change in the resident's condition for one (Resident #186) of one resident reviewed. Specifically, Resident #186 had a potential serious complication with their tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway to assist with breathing) tube. This is evidenced by the following: The facility policy Notification of Change, revised April 2021, documented the appropriate department will immediately consult with the resident's physician when there is a significant change in the resident's physical status. [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (#NY00321703), the facility did not ensure the resident's right to be free from physical abuse for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was slapped on the hand by a staff member that was observed by other staff and on video. The is evidenced by the following: The facility policy, Abuse Prohibition Program, dated revised on 9/15/22, included that under no circumstances would the facility tolerate resident abuse, neglect, mistreatment, misappropriation of resident property, or resident exploitation. Physical abuse would include hitting, slapping, pinching, and kicking, or controlling behavior through the use of corporal punishment. Resident #1 had diagnoses that included Alzheimer's disease, dementia, and lack of coordination. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey 4/24/23 to 5/1/23, it was determined that for 1 (Resident #328) of 35 residents reviewed for care plans, the facility did not ensure that a resident's care plan was revised to reflect the resident's current condition. Specifically, the residents comprehensive care plan (CCP) was not revised related to the resident's smoking habits, a history of burns to the hands and fingers sustained while smoking, interventions for staff to utilize and any refusals of interventions. This is evidenced by the following: The facility policy, Smoking Policy, dated as revised 4/4/22, documented that the facility was a smoke free environment where smoking will not be allowed by residents on the facility campus. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey 4/21/23 to 5/1/23, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible for one (Resident #202) of 10 residents reviewed for accidents. Specifically, Resident #202 who had a history of keeping vaping materials in their room, and was suspected of vaping in their room, had 6 vape pens with cartridges in their room. Additionally, during a room search on 4/27/23, a security officer recovered several containers of marijuana, 2 boxes of vape liquid, 2 lighters, 1 torch lighter, and 1 marijuana pipe. The finding is: The facility Smoking Policy, revision dated 4/4/22, documented the facility designated itself a smoke-free campus as of 5/1/22. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00276844), 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. There was no Comprehensive Care Plan (CCP) related to smoking or burns due to smoking. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00276844), completed on 7/15/21, it was determined that for one resident (Resident #243) of three residents, the facility did not ensure that alleged violations of abuse, neglect, or mistreatment, including injuries of unknow origin were reported to the Administrator and the State Agency in a timely manner. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) that Resident #243 sustained an injury while smoking unsupervised until 5 weeks after it occurred. This was evidenced by the following: The facility policy, Accident and Incident Review and Prevention- Residents included all reportable events would be electronically reported per regulatory requirements. [...]