Monroe Rehabilitation Center
Monroe Rehabilitation Center in Monroe, NC — inspection on September 30, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the facility and based on the history of Resident #1 behaviors; there was no evidence of abuse to
9/12/2025 at 2:14 pm a phone interview was conducted with Physician #1. He stated Resident #1
nursing staff and physician in the past. He explained Resident #1 was declining cognitively and in her health due to the disease process of dementia. He stated Resident #1 had not displayed any new behaviors in the last 2 to 3 months.A Psychiatry physician progress note dated 9/12/2025 indicated Resident #1 was evaluated for potential emotional disturbances following a social media post by a nursing team employee.
The physician documented Resident #1 was alert to self but exhibited chronic confusion regarding time and place due to Alzheimer's dementia.
The Psychiatrist recorded there were no acute behavioral disturbances, impulsivity, restlessness or agitation observed during the visit.
There was no recommendation to change Resident #1's medications at the time and recommended to continue monitoring Resident #1 for changes in her condition.The investigation report dated 9/16/2025 for an allegation of abuse was completed by the Administrator and sent to the State Agency.
The investigation report recorded the local law enforcement agency and Adult Protective Services (APS) were notified and NA #1 was terminated from employment on 9/16/2025 for not following the facility's social medial policy. Resident #1 was assessed by the nursing staff and the physician with no new behaviors or physical findings.
The facility conducted skin assessments on all residents with a Brief Interview for Mental Status (BIMS) score of 12 or less with no findings of abuse.
Interviews on the use of phones and social media by staff in resident care areas were conducted with residents with a BIMS score of 13 or greater with no new findings identified.
Facility staff were interviewed on phone/social media usage in resident care areas in the facility with no reports of witnessing nursing staff electronically videoing residents.
All staff were educated on the facility's social media policy, abuse policy and how to care for residents with dementia and aggressive behaviors. At the completion of the investigation by the facility, the facility reported the allegation of abuse was not substantiated because the recorded video of Resident #1 did not provide evidence that NA #1 willfully intended to hurt, harm, intimidate or punish Resident #1 by any means.
The investigation report indicated Resident #1 was safe and had not suffered any injuries or mental anguish.On 9/24/2025 at 12:03 pm in a phone interview with the Administrator, he explained based on the screen displaying the recorded video of Resident #1, the facility determined that the recorded video of Resident #1 shared with the facility on 9/10/2025 was not from a social media site and the recorded video of Resident #1 was from NA #1's camera roll located on NA #1 personal cellular phone device. He explained Caller #1 was told by the facility to delete the video recording of Resident #1 that Caller #1had uploaded onto her personal cellular device and use to report to the facility.
The Administrator stated NA #1 had reported during her interview, she had already deleted the recorded video of Resident #1 from her personal cellular phone device. He further stated neither Caller #1 nor NA #1 had been to the facility as requested to verify the recorded video of Resident #1 had been deleted from their personal cellular phone devices.On 9/24/2025 at 12:18 pm in a phone interview with Caller #1, she stated as instructed by the facility, she had deleted the recorded video of Resident #1 that she had uploaded to her personal cellular phone device on 9/9/2025.
345254 09/30/2025
Monroe Rehabilitation Center 1212 Sunset Drive East Monroe, NC 28112
Based on the audit results, the Quality Assurance Performance Improvement committee will determine the need of further monitoring for residents with a change in condition for mobility/transfers.
Compliance Date: 9/8/2025 On 9/12/2025, the facility's corrective action plan was validated by the following documentation: Residents' EMR for change in condition the past 2 weeks were reviewed by Assistant Director of Nursing on 9/5/2025 with no concerns identified.
Physician orders in residents' EMR were reviewed for the past 2 weeks by the DON on 9/5/2025 with no concerns identified.
The physician communication book was reviewed for the past 2 weeks by the DON 9/5/2025 with no concerns identified.
Incident reports for the past 2 weeks were reviewed by the DON 9/5/2025 with no concerns identified.
Body audits for residents with a BIMS less than a 12 were assessed to identify changes in mobility and transfer status and notification of physician and resident representative by the Assistant Director of Nursing and unit managers on 9/6/2025 with no change or injury identified.
Residents with a BIMS greater than 13 were interviewed for changes in mobility and transfer status by the Assistant Director of Nursing and DON on 9/5/2025 with no falls identified and not reported to the nursing staff.
Educational sign in sheets starting 9/3/2025 recorded nursing staff ( nurses and nurse aides) received education in-services on change of condition, recognizing and assessing a change in resident and notifying the nurse and notification of the physician of a change in resident's condition.
Interviews with the nursing staff verified education in-services were conducted for the nursing staff as indicated in the POC.
The facility's compliance date was validated as 9/8/2025.
345254 09/30/2025
Monroe Rehabilitation Center 1212 Sunset Drive East Monroe, NC 28112
#1 stated the snake had already been removed by a staff member and the Administrator reported the
Contracted Pest Control Company Technician had informed the receptionist that the wildlife
was inspected exteriorly by the Maintenance Director, and an interior inspection was conducted by the Administrator with no further snake findings reported. In an interview with the Maintenance Director on 9/11/2025 at 3:10 pm, he stated the facility did not have snake repellent materials to applied exteriorly to the building. A Wildlife Department report dated 8/29/2025 recorded the building was surveyed interiorly and exteriorly and there were no snakes removed from the building.
The wildlife department technician recorded snake deterrent was applied around every door of the building to prevent future entry of snakes. In a phone interview with the Wildlife Department Technician on 9/12/2024 at 12:22pm, he stated on 8/29/2025 there were no snakes or mice observed in the building and snake deterrent material was applied around the doors exteriorly. He explained snake deterrent materials were not applied in the interior of the building and encouraged the facility to keep the exterior grounds and interior rooms and offices clean to deter pest that may attract snakes. He explained snake deterrent treatment should last for 4-6 months and the facility should consider retreating with a snake deterrent in the springtime. In an interview with the Administrator on 9/11/2025 at 12:35 pm, he explained there was not a resident safety concern because when the snakes were observed in the building, the snakes were not close to a resident and were disposed of immediately. He stated there had been no further sighting of snakes in the building since the wildlife department technician applied deterrent outside the building around the doors. In an interview with the Regional [NAME] President of Operations on 9/11/2025 at 12:40 pm, he stated there was a repairman scheduled to come to the facility on 9/11/2025 to close the half inch opened space area between the two front entrance doors where pests could enter the building. On 9/12/2025 at 2:30pm, the front entrance doors were observed with the half inch open space at the bottom when the two front doors were closed.
There was enough space for a snake to enter the building.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.