01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-08-14 | 6 | 2024-08-14 | 0 |
| Cycle 2 | 2023-07-14 | 5 | 2023-07-14 | 2 |
| Cycle 3 | 2021-04-09 | 8 | 2021-04-09 | 3 |
CMS CCN 3754152026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Monroe Manor
226 E Monroe Street · Jay, OK 74346 · Delaware County
Certified beds98CMS provider file
Recent citation rows24current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
24 rows in the current release
3 rows carry G–L scope/severity codes; 1 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-23 · HEALTHF0605Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has plan of correction · 2026-07-31 · complaint2024-09-23 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-10-21 · complaint2024-09-23 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Correction field: Deficient, Provider has date of correction · 2024-10-21 · complaint2024-09-23 · HEALTHF0695Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-10-21 · complaint2024-08-14 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-10-042024-08-14 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2024-10-042024-08-14 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-10-042024-08-14 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-10-042024-08-14 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-10-042024-07-23 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-08-26 · complaint2024-05-28 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-06-06 · complaint2024-05-28 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-06-06 · complaint2024-01-30 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-02-23 · complaint2024-01-23 · HEALTHF0557Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2024-02-13 · complaint2024-01-23 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-02-15 · complaint2024-01-23 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-02-15 · complaint2023-07-14 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2023-08-252023-07-14 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-08-252023-07-14 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-12-082023-07-14 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2023-12-082021-04-09 · FIREE0001Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2021-05-052021-04-09 · HEALTHF0688Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2021-05-052021-04-09 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2021-05-052021-04-09 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2021-05-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-07-23 | Fine | $23,755 | 0 |
| 2024-01-23 | Fine | $8,018 | 0 |
| 2024-01-23 | Payment Denial | $0 | 8 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MONROE MANOR NURSING, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/2023
- RHINE, ZVIIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 01/01/2023
- MONROE MANOR NURSING, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2023
- TLC ERETZ MANAGEMENT LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2022
- AGUIRRE, AYOIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/20/2025
- MEASE, DARRELLIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2022
- RHINE, ZVIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2022
- TLC ERETZ MANAGEMENT LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2022
- AGUIRRE, AYOIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/20/2025
- MEASE, DARRELLIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/01/2022
- RHINE, ZVIIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.60per resident day
RN hours0.47per resident day
Weekend nurse hours3.33per resident day
Staff turnover60.0%CMS reported field
06 / LOCAL RECORDS
Open the Oklahoma ledger →Other published facilities nearby
No second facility in the same city met the directory rule.