Monroe Community Hospital
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monroe Community Hospital
435 East Henrietta Road Rochester, NY 14620
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0686
F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
long-term exposure to moisture). Director of Nursing #2 stated the wound team first saw Resident #1 for their sacral pressure ulcer on 09/23/2025.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they review hospital information and see residents upon return but do not always document the visit. They stated nurses report new concerns through the communication log, which Nurse Practitioner #1 initialed when reviewed, and assessed the resident as needed. Nurse Practitioner #1 stated
they recalled seeing Resident #1 for pain and observing a small open area on their sacrum, applying barrier cream, and alerting the wound team; they could not recall the date of the visit. They later saw the worsening wound at the wound team's request; they could not recall the date of the visit. Nurse Practitioner #1 stated they may not document every resident visit and were not aware Resident #1 missed wound assessments on 09/12/2025 and 09/17/2025. They expected the wound team to notify them if the wound team was unable to see a resident.The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/21/2025 at 4:38 PM.On 10/21/2025 at 8:15 PM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility: All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness. The survey team reviewed additional residents with no identified concerns. The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment 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)
Event ID:
Facility ID:
If continuation sheet
Monroe Community Hospital in Rochester, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Rochester, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Monroe Community Hospital or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.