Monroe Health & Rehab: Undocumented Fall Injuries - VA
The resident described the sequence themselves during an interview with inspectors on August 21, 2025. "They didn't even do an x-ray which I thought was odd," the resident said of the first hospital. "They put two big ace bandages on it and when I got back they decided I needed to go back." The second hospital confirmed the hematoma and found other issues, keeping the resident for several days.
What Monroe staff documented during all of this was thin. Treatment orders appeared in the clinical record. A detailed wound assessment did not.
The director of nursing, interviewed the same morning inspectors were on site, said the skin tear was "superficial" and that this judgment was the reason no detailed documentation was made. She offered no further explanation.
The facility's own policies said otherwise. Monroe's incident and accident policy, revised as recently as October 2024, required that documentation and assessment be completed after any incident, including neurological assessment when indicated. Its skin and wound care policy, updated in September 2023, called for wounds other than pressure injuries to be assessed every shift, with each assessment covering location, size, drainage, pain, wound bed condition, tissue color and type, the appearance of surrounding tissue, and any signs of infection.
None of that appears to have been done here, at least not in any way that made it into the record.
The gap matters for a reason that goes beyond paperwork. A wound that looks minor at first glance can change. A hematoma, which is a pooling of blood in tissue, can expand, become infected, or signal deeper injury. Shift-by-shift documentation exists precisely so that nurses coming on duty can see what the wound looked like eight hours ago and whether it is getting better or worse. Without that record, the progression of an injury becomes invisible to everyone except whoever happened to be in the room.
In this case, the resident's condition did get worse, or at least more complicated, quickly enough that the facility sent them back out to a second hospital. The second hospital found problems that the first hospital had missed and that Monroe's own staff, by the director of nursing's account, had not considered serious enough to document in detail.
Inspectors cited the deficiency under a standard requiring that services be provided in accordance with professional standards of quality. The level of harm was assessed as minimal harm or potential for actual harm, and the violation was noted to affect a small number of residents.
On the afternoon of August 21, inspectors met with the facility administrator, director of nursing, medical director, and corporate staff to discuss what they had found. No additional information was offered.
The resident who described going through two hospitals, several days of inpatient care, and a hematoma diagnosis was not offered a different account by anyone in that room.
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 3, 2026 · Our methodology
MONROE HEALTH & REHAB CENTER in CHARLOTTESVILLE, VA was cited for violations during a health inspection on August 21, 2025.
The resident described the sequence themselves during an interview with inspectors on August 21, 2025.
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.