Monroe Health & Rehab: Resident Sent to ER, Records Lost - VA
Nobody had tried to get them.
The resident, identified in inspection records only as R17, was on long-term anticoagulation therapy, meaning his blood doesn't clot normally. When he developed a hematoma, his physician documented concern about blood loss and strongly encouraged him to go to the emergency department for evaluation, possible x-rays, and blood testing. R17 agreed and was sent out by emergency medical services on July 29, 2025.
What happened at the hospital that day should have been in his clinical record when he returned. It wasn't.
When a surveyor arrived at Monroe Health & Rehab on August 21 and asked the director of nursing for R17's hospital records, the director said staff were working to obtain them. The surveyor then asked the medical director whether he had access to the records. He said he did not, and suggested that perhaps R17 or his spouse could get them.
The medical director of a nursing home, directing a surveyor to ask the patient's family to retrieve records from a hospitalization that happened three weeks earlier.
Later that same morning, the surveyor pressed the director of nursing about whether a quality improvement plan had been developed for the July 29 incident, similar to one that had been created after an earlier incident in October 2024. The director of nursing said there was no such plan. Her explanation: "The skin tear was superficial."
When asked about x-ray imaging, the director of nursing said R17 had refused, so none was obtained at the facility.
At 10:45 that morning, the survey team sat down with the facility administrator, the director of nursing, and corporate staff. The group reported they had no further information to provide.
It was during that same meeting that the assistant director of nursing confirmed staff had reached out to the hospital to request copies of R17's records. The surveyor asked a direct question: had anyone contacted the hospital before that morning, before the surveyor started asking for the documents?
The assistant director of nursing said, "Not that I am aware of."
Every administrator in the room then confirmed that the expectation, the standard practice, would have been for hospital records to be incorporated into R17's clinical file automatically upon his return. They acknowledged the records should have been there. They were not.
The inspection tagged the deficiency at F0689, the federal citation covering accidents and supervision, and rated it as causing actual harm to residents.
What the record does not show is what the hospital found when R17 arrived on July 29. Whether his hematoma had grown. Whether his blood levels were dangerously off. Whether he needed treatment that his nursing home never followed up on. Those answers sat in a hospital file that Monroe Health & Rehab spent three weeks not requesting.
The director of nursing called it a superficial skin tear. The physician who examined R17 that day used different language: chronic anticoagulation, hematoma development, subsequent blood loss, emergent evaluation.
R17 went home from the hospital at some point. He returned to Monroe Health & Rehab. And for twenty-three days, the people responsible for his care had no documentation of what had been found or done during a hospitalization his own doctor had called an emergency.
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.
The resident, identified in inspection records only as R17, was on long-term anticoagulation therapy, meaning his blood doesn't clot normally.
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.