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
jeopardy to resident health or safety
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
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Monroe Community Hospital
435 East Henrietta Road Rochester, NY 14620
SUMMARY STATEMENT OF DEFICIENCIES
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)
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