Monroe Rehabilitation Center: Care Assessment Failures - NC
The deficiency was rated as causing minimal harm or potential for actual harm and affected a small number of residents. But the facility's own corrective response revealed how far the lapse had spread: nurses and nurse aides across the building had to be retrained, some by phone, over a five-day stretch beginning September 3.
The Director of Nursing personally conducted the education push, reaching staff before their next scheduled shifts. Anyone hired after September 7 would go through the same training during clinical orientation. Sign-in sheets were kept as proof the instruction had been received and understood.
Before the retraining was finished, the Assistant Director of Nursing and unit managers were already moving through the building, conducting physical assessments of residents with cognitive scores below a certain threshold to look for undetected changes in mobility or transfer ability. Residents with higher cognitive scores were interviewed directly. The Director of Nursing pulled two weeks of incident reports, physician communication logs, and electronic medical records, reviewing all of them on September 5. No injuries turned up. No falls had gone unreported to nursing staff, according to residents who were interviewed.
The facility set a compliance date of September 8. A validator reviewed the corrective action four days later and confirmed the date held.
Going forward, the Director of Nursing or a designee is required to review daily incident reports, 24-hour progress notes, and change-of-condition forms every day for four weeks, then monthly for two months after that. Any time a change in condition is identified, the audit must confirm a nurse evaluated the resident and that the physician and the resident's representative were told.
Whether any resident experienced a decline during the period when assessments were being missed, before inspectors arrived and the scramble began, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monroe Rehabilitation Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Monroe Rehabilitation Center in Monroe, NC was cited for violations during a health inspection on September 30, 2025.
The deficiency was rated as causing minimal harm or potential for actual harm and affected a small number of residents.
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.