Monument Healthcare Stonecreek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for 2 out of 40 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident left the facility and called his daughter to report he was lost and a week later another resident, who needed to be supervised during a Leave of Absence, left the facility. Resident identifiers: 29 and 110.Findings included:1. Resident 110 was admitted to the facility on [DATE] and discharged on 3/27/26 and readmitted on [DATE] and discharged on 6/2/26 with diagnoses which included depression, alcohol dependence, and history of transient ischemic attack. The facility reported to the State Survey Agency (SSA) on 5/22/26 at 11:32 AM, that resident 110 took an uber to get a haircut and called his daughter because he did not know how to get back on 5/14/26 at 11:35 AM. The daughter called the facility and they went and picked him up. It should be noted the incident happened on 5/21/26, not 5/14/26 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 out of 8 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident was not provided wound vac supplies in a timely manner. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.A review of resident 2's medical record revealed the following:a. On 6/5/25 at 7:02 PM, a progress note documented, Resident back from wound clinic appointment from [local hospital]. Notes state to order wound vac, and send it with patient to next appointment and doctor wants patient to do hyperbaric oxygen therapy, team at [facility] needs to talk about a decision. Resident aware of orders. DON [Director of Nursing] [name…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 out of 8 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents were not provided multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifiers: 2 and 8.Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.Resident 2's medical record was reviewed on 1/5/26.A review of resident 2's medication orders revealed:a. Glimepiride Oral Tablet 4 MG [milligram] Give 4 mg by mouth at bedtime for T2DM [Type 2 diabetes mellitus]. The start date of this medication was 5/15/25.b. Eucerin Advanced Repair External Cream (Emollient) Apply to [NAME] [bilateral] Lower extremites [sic] topically two times a day for Dry scaley [sic] skin. The start date of this medication was 5/26/25. c. Amitriptyline HCI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, 1 out of 8 sampled residents did not receive their intravenous (IV) antibiotics every 8 hours as ordered by the hospital. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.Resident 2's medical record was reviewed on 1/5/26.A review of resident 2's hospital discharge orders dated 5/15/25 at 1:08 PM, documented Cefazolin 2 GM [gram] (TRADE NAME: ANCEF 2 GM/100 ML [milliliters] IVPB) [intravenous piggyback] INTRAVENOUS EVERY 8 HOURS 50 days. The last dose was documented as being received on 5/15/25 at 7:24 AM at the hospital.A review of resident 2's medication orders revealed: a. On 5/15/25 an order for CeFAZolin Sodium Solution Reconstituted 1 GM Use 2 gram intravenously every 24 hours for infection for 50 Days.b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, an insulin pen and a vial of Lidocaine were not labeled with an open date and were open and available for use. In addition, narcotics were repackaged into the narcotic cards. Findings included: 1. On 4/24/24 at 8:25 AM, an observation was made of the 100 hallway medication cart with Registered Nurse (RN) 1. A pre-filled pen of Lantus 100 units/milliliter was open and available for use. No open date could be seen on the pen. On 4/24/24 at 8:30 AM, an interview was conducted with RN 1. RN 1 stated the medications that were in the cart were currently being used for the residents. RN 1 stated when an insulin pen was taken out of the medication room the nurses were supposed to label it with an open date. RN 1 stated insulin was good for 30 days after it was opened but could not say how long this insulin pen was good…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident that was dependent on staff and required maximum assistance for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and received contusions and suffered emotional distress. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, esophageal varices without bleeding, hepatic encephalopathy, urinary tract infection, alcoholic cirrhoses of the liver with ascites, gastroesophageal reflux disease with esophagititis, essential hypertension, vitamin deficiency, mixed hyperlipidemia, hypothyroidism, gastrointestinal hemorrhage, ileus, anemia, and muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record the review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 26 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication in a timely manner. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, esophageal varices without bleeding, hepatic encephalopathy, urinary tract infection, alcoholic cirrhoses of the liver with ascites, gastroesophageal reflux disease with esophagititis, essential hypertension, vitamin deficiency, mixed hyperlipidemia, hypothyroidism, gastrointestinal hemorrhage, ileus, anemia, and muscle weakness. Resident 41's medical record was reviewed on 4/24/24. On 4/24/24 at 8:15 AM, during morning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 26 sampled residents, behavioral health services were not provided to a resident who was assessed to need them. Resident identifier: 29. Findings included: Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, osteomyelitis, infection of amputation stump of right lower extremity, methicillin resistant staphylococcus aureus infection, acute respiratory failure with hypoxia, atrial septal defect as current complication following acute myocardial infarction, major depressive disorder, insomnia, congestive heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 1 of 5 sampled residents that the facility did not notify the facility's physician or resident representative of a significant change in a resident's physical, mental, or psychosocial status. Specifically, the facility did not inform a resident's physician of the resident's change in mental status prior to sending her out for a hemodialysis appointment. Upon arrival to the appointment, the hemodialysis center then sent the resident out to the hospital due to her altered mental status. Resident Identifier: 1 Findings include: Resident 1 was originally admitted [DATE], readmitted [DATE], with diagnoses including, but not limited to: nontraumatic subdural hemorrhage unspecified, other encephalopathy, epilepsy unspecified not intractable without status epilepticus, end stage renal disease, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, hypotension unspecified, Alzheimer's disease unspecified, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review it was determined, for 1 of 31 sampled residents, that the facility did not treat each resident with respect and dignity and cared for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, one resident with intact cognition and no episodes of elopement had a wander guard placed on her ankle which limited her mobility and independence. Resident identifier: 11. Findings included: Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease, epilepsy, seizures, pseudobulbar effect, history (hx) of traumatic brain injury, encephalopathy, Alzheimer's disease, hx of falls, muscle weakness, mild cognitive impairment, dementia, and exophoria. On 2/18/20 at 11:15 AM, resident 11 was interviewed. Resident 11 was observed to have a wander guard on her left ankle. Resident 11 stated that she enjoyed going out of the building…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 31 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. Specifically, a resident to resident altercation occurred in which a resident threw a garbage can at another resident and the altercation was not reported to the State Survey Agency. Resident identifiers: 52 and 169. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, chronic kidney disease, hypertension,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 31 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who was receiving Hospice services and had significant weight loss was not coded accurately on the significant change Minimum Data Set (MDS) assessment. In addition, a resident with a wanderguard elopement alarm was not coded accurately on the MDS assessments as having the alarm. Resident identifiers: 11 and 28. Findings include: 1. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease, dementia without behavioral disturbance, mild intellectual disabilities, edema, repeated falls, and pain. The MDS Resident Matrix provided by the facility upon entrance was reviewed. Resident 28 was checked for receiving Hospice services and as having an excessive weight loss without a prescribed weight loss program. Resident 28's medical record was reviewed on 2/29/20. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined the facility did not establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of a Certified Nursing Assistant (CNA) simultaneously assisting two residents with eating without utilizing adequate hand hygiene practices. Findings include: On 2/18/20, the following observations were made throughout lunch meal service within the secured unit: a. At 11:33 AM, two residents were observed sitting at the same table and feeding themselves utilizing their own silverware. b. At 11:45 AM, CNA 3 was observed to provide a bite of food to one of the two residents utilizing the resident's silverware. c. At 11:49 AM, CNA 3 provided a bite of food to the second resident utilizing the resident's silverware. CNA 3 was subsequently observed to smooth the resident's hair. d. At 11:52 AM, CNA 3 provided a bite of food to the first resident utilizing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, observations were made of unclean chairs within the dining room located on the secured unit. Findings include: On 2/18/20 at 11:30 AM, observations were made throughout lunch meal service within the dining room located on the secured unit. A Certified Nursing Assistant (CNA) was observed to take a roll of plastic bags out of her pocket, tear off one plastic bag, and cover the seat of a dining room chair prior to sitting down. Furthermore, a second CNA was observed sitting on a chair that was also covered with a plastic bag. On 2/18/20 at 2:17 PM, additional observations were made within the dining room located on the secured unit. Three recliners were observed side by side, two of which were constructed with leather-like material and the third constructed with fabric. A CNA was observed assisting a resident out of the fabric recliner, and the resident's pants were observed to be wet. The CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.