Monroe Community Hospital
Monroe Community Hospital in Rochester, NY — inspection on October 24, 2025.
Found 2 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
PM, Director of Nursing #1 stated bowel movement reports were printed on Mondays, Wednesdays,
jeopardy to resident health or movement.
They stated the reports were intended to alert staff for follow-up.
During an interview on safety 10/15/2025 at 5:33 PM, Licensed Practical Nurse #6 stated bowel movement lists were printed daily, identified residents without a bowel movement in three (3) days, and were reviewed during morning
were ordered, and certified nursing assistants were instructed to notify them when a bowel movement occurred so it could be documented.
During an interview on 10/16/2025 at 1:43 PM, Registered Nurse Manager #1 stated bowel movement reports were printed three (3) times per week and reviewed with certified nursing assistants.
They stated the electronic medical record would generate alerts at 24, 48, and 72 hours for residents without a bowel movement.
Registered Nurse Manager #1 stated most residents were on bowel regimens and the bowel management process involved the use of as needed medications.
They were unable to locate a written bowel protocol upon request.
During an interview on 10/16/2025 at 2:56 PM with Director of Nursing #1 and Director of Nursing #2, Director of Nursing #1 stated if a resident had several as needed medications for constipation, the nurse should review the medication indication to determine which medication to use.
Director of Nursing #2 stated the nurse should start with the least restrictive medication.
Director of Nursing #1 stated there were no bowel movement entries for Resident #1 from 09/24/2025 through 10/03/2025 and believed someone may have forgotten to document a bowel movement.
Director of Nursing #1 stated they had no explanation for how this was not identified despite bowel alerts and reports.
During a follow-up interview on 10/21/2025 at 11:32 AM, Medical Director #1 stated a resident could have leakage of stool around a bowel impaction.
They stated Resident #1's bowel impaction was likely preventable because interventions were not implemented.
They stated Resident #1 was at high risk for constipation due to immobility and a neurologic condition and would have expected bowel management to be addressed when Resident #1 returned from the hospital.During a telephone interview on 10/24/2025 at 11:49 AM, Licensed Practical Nurse #2 stated bowel movement reports had been printed daily until a system upgrade six (6) months earlier.
After the upgrade, reports were printed every other day and then only on Mondays, Wednesdays, and Fridays.
Licensed Practical Nurse #2 stated they had been serving as an interim charge nurse since 08/06/2025 and 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 09/24/2025 through 10/03/2025 and would have expected to be informed.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they expected staff to notify them if a resident had not had a bowel movement in more than two (2) days or was experiencing discomfort.
They stated the facility did not have a bowel protocol and most residents were on bowel regimens.
Nurse Practitioner #1 stated they specified the order bowel medications were to be administered when prescribing the medications.
They stated they were unaware Resident #1 had not had a bowel movement from 09/24/2025 through 10/03/2025 or from 10/09/2025 through 10/16/2025.
The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/17/2025 at 2:30 PM.On 10/20/2025 at 10:45 AM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility:The facility provided a copy of the defined Bowel Management Regimen policy and procedure, dated 10/17/2025.
The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports.
The facility provided supporting documentation for 85.5% of nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift.
Interviews with several staff revealed appropriate knowledge of the bowel management process.A list of all facility residents who did not have a documented bowel movement in three (3) days was provided.
Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns. 10 NYCRR 415.12
335197 10/24/2025
Monroe Community Hospital 435 East Henrietta Road Rochester, NY 14620
The survey team reviewed additional residents with no identified concerns.
The
jeopardy to resident health or would be screened by a member of the wound care team to ensure appropriate skin care treatment safety plan was initiated.100% of Wound Care staff received re-education on the revised policy and procedure.
The survey team verified the education through staff interviews. 10 NYCRR 415.12(c)(1)(2)
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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.