Monroe Health & Rehab: Missing Hospital Records - VA
The fall happened around noon. The physician who examined Resident 17 found swelling on the outer side of his left thigh and knee, marked the edges of the hematoma with a pen, and measured it: 19 centimeters long, 14 centimeters wide. He ordered the leg elevated, an ice pack applied, and said he'd return in an hour.
He came back at 3:30 p.m. The hematoma had grown. It was now 21 centimeters long and 18 centimeters wide. The resident was uncomfortable and visibly frustrated. The physician noted his concern about the man's chronic anticoagulation, meaning the resident was on medication that prevents blood from clotting normally, which made the expanding bleed more serious. He strongly encouraged the resident to go to the emergency department. The resident agreed, and he left by ambulance.
That was July 29, 2025.
When state surveyors arrived at Monroe Health & Rehab on August 21, they asked to see the hospital records from that visit. The facility didn't have them.
The director of nursing told surveyors at 10 a.m. that staff were working to obtain the records. The medical director said he didn't have access to them either, and suggested that maybe the resident or his spouse could get them. By 10:45 a.m., surveyors were sitting across from the facility administrator, the director of nursing, and corporate staff. They had nothing further to offer.
The assistant director of nursing confirmed that the facility had reached out to the hospital that morning, the same morning surveyors started asking for the documents. When asked whether anyone had contacted the hospital before that day, in the three weeks since the resident had been sent out by ambulance, the assistant director of nursing said: "Not that I am aware of."
Every administrator in that room agreed that the expectation was for hospital records to be part of a resident's clinical file. They acknowledged it. They just didn't have the records.
The deficiency was cited under F0842, which covers the accuracy and completeness of clinical records. Inspectors rated it as having minimal harm or potential for actual harm, affecting a few residents.
What the record doesn't show is whether anyone at Monroe Health & Rehab ever learned what the emergency department found, whether Resident 17 had a fracture, whether his blood levels required intervention, or what follow-up care he needed when he returned. Those answers would have been in the hospital records. The facility didn't ask for them for three weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monroe Health & Rehab Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
MONROE HEALTH & REHAB CENTER in CHARLOTTESVILLE, VA was cited for violations during a health inspection on August 21, 2025.
He ordered the leg elevated, an ice pack applied, and said he'd return in an hour.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.