Monroe Community Hospital: Bowel Impaction Jeopardy - NY
Federal inspectors declared immediate jeopardy on October 17, 2025, following a complaint inspection at the facility at 435 East Henrietta Road. The resident at the center of the case, identified in inspection records only as Resident #1, had gone without a documented bowel movement from September 24 through October 3, a period of ten days. They then went without one again from October 9 through October 16.
The resident was at high risk. Immobility and a neurologic condition, both documented in the inspection report, are known drivers of constipation. Medical Director #1 told inspectors during a follow-up interview on October 21 that the resident would have expected bowel management to be addressed specifically when Resident #1 returned from the hospital. They also noted that a resident can have leakage of stool around a bowel impaction, a detail that makes the absence of documentation even harder to explain: the physical signs were there to be seen.
Nobody connected them.
What inspectors found when they started asking questions was not a single failure but a system that had quietly come apart over months, with each person responsible for a piece of it unaware of what the others were or weren't doing.
Licensed Practical Nurse #2, who had been serving as an interim charge nurse since August 6, 2025, told inspectors in a telephone interview on October 24 that they had not understood the bowel alerts in the electronic medical record until recently receiving education. They were not aware Resident #1 had not had a bowel movement from September 24 through October 3 and said they would have expected to be informed.
That expectation ran in every direction at once, and nobody was actually catching anything.
The monitoring system itself had degraded without anyone formally accounting for it. Licensed Practical Nurse #2 explained that bowel movement reports had been printed daily until a system upgrade six months earlier. After the upgrade, reports shifted to every other day, and then to only Mondays, Wednesdays, and Fridays. That change, from daily to three times a week, cut the frequency of human review nearly in half. There is nothing in the inspection record indicating the facility formally recognized this as a change requiring staff retraining or protocol adjustment.
When inspectors asked Registered Nurse Manager #1 for a written bowel protocol on October 16, they were unable to locate one.
That was the situation on the ground: a high-risk resident, a system upgrade that reduced monitoring frequency, an interim charge nurse who didn't fully understand the electronic alerts, no written protocol, and a nurse practitioner who expected to be called if a resident hadn't moved their bowels in more than two days. Nurse Practitioner #1 told inspectors they were unaware Resident #1 had not had a bowel movement from September 24 through October 3, and also unaware of the second stretch from October 9 through October 16.
They were never called.
Director of Nursing #1, interviewed alongside Director of Nursing #2 on October 16, acknowledged there were no bowel movement entries for Resident #1 from September 24 through October 3. They said they believed someone may have forgotten to document a bowel movement. Then they said they had no explanation for how this was not identified despite bowel alerts and reports.
That admission is worth sitting with. The electronic medical record was generating alerts. Reports were being printed. Morning reports were happening. Certified nursing assistants were supposed to notify nurses when a bowel movement occurred. And still, for ten days, nothing surfaced about a resident who was immobile, neurologically compromised, and going without any documented bowel movement at all.
Director of Nursing #1 said if a resident had several as-needed medications for constipation, the nurse should review the medication indication to determine which to use. Director of Nursing #2 said the nurse should start with the least restrictive medication. These were reasonable things to say. They were also instructions that presuppose a nurse knows to act, which presupposes someone has flagged that a resident needs intervention, which presupposes the monitoring system is functioning. None of those conditions held.
Licensed Practical Nurse #6, interviewed on October 15, described a process that sounded orderly: bowel movement lists printed daily, residents without a movement in three days identified, the list reviewed during morning report, medications administered or providers notified, nursing assistants instructed to report bowel movements for documentation. What LPN #6 described and what actually happened for Resident #1 during those ten days are not reconcilable.
The immediate jeopardy designation was removed on October 20, three days after the administrator was notified. The facility moved quickly. By October 17, the same day inspectors notified the administrator, Monroe Community Hospital had drafted and dated a formal Bowel Management Regimen policy and procedure. Copies were placed in binders on each residential unit alongside current bowel movement reports. The facility documented that 85.5 percent of nursing staff had received education on the new policy, with attestations that remaining staff would be trained before their next scheduled shift. Interviews with several staff members confirmed they understood the process.
A list of all residents who had not had a documented bowel movement in three days was produced, along with records showing as-needed medications had been offered and given, with no new concerns identified.
The speed of the corrective response is notable. A formal written protocol that did not exist on October 16 existed on October 17. Staff education that had not happened was happening within days. The infrastructure that inspectors found missing was assembled in roughly 72 hours.
Which raises the question the inspection report does not answer: why it took a federal complaint inspection to build it.
The facility had an electronic medical record system generating alerts. It had nurses who understood, in general terms, that bowel monitoring mattered. It had a nurse practitioner who had specified the order in which bowel medications should be given. It had directors of nursing who could articulate what a nurse should do when constipation was a concern. What it did not have was a written protocol, consistent monitoring frequency after a software upgrade, or a charge nurse who understood the alert system they were responsible for acting on.
Resident #1 was immobile. They had a neurologic condition. They had just returned from the hospital. Their medical director said bowel management should have been addressed at that point specifically. Instead, the ten-day gap began.
The medical director also noted that a resident can have leakage of stool around a bowel impaction. That is not a subtle symptom. It is something that would be visible during routine care, during repositioning, during any of the interactions that occur between nursing staff and a resident who cannot move independently. The inspection report does not say whether anyone observed it and failed to report it, or whether it went unnoticed entirely. What it says is that the impaction was likely preventable, and that interventions were not implemented.
Resident #1's name does not appear in the inspection report. Their diagnosis, beyond immobility and a neurologic condition, is not described. What happened to them after the impaction was identified is not in the record inspectors made public. The file closes with corrective actions taken and immediate jeopardy removed.
What the file does not close is the question of what those ten days were like for someone who could not move, could not advocate for themselves, and was waiting for a system that had stopped working to notice they needed help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monroe Community Hospital from 2025-10-24 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 Community Hospital in Rochester, NY was cited for violations during a health inspection on October 24, 2025.
Federal inspectors declared immediate jeopardy on October 17, 2025, following a complaint inspection at the facility at 435 East Henrietta Road.
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.