Monument Healthcare and Nursing Center

In the surveyor’s words

From the most serious findings on record at Monument Healthcare and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 28, 2023

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A(1) LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, record review, and interviews; the facility failed to have measures in place to prevent the spread of COVID-19 (a mild to severe respiratory illness that is caused by a coronavirus) related to hand hygiene, doffing (removing) Personal Protective Equipment (PPE), mask use, quarantine of COVID-19 positive residents and the use of disposable supplies for meal service. […]

• Immediate jeopardy, isolatedF678Aug 1, 2024

  Licensure Reference Number 175 NAC ,d+[DATE].09 Based on record reviews and interviews; the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for three residents (Residents 40, 32 and 46). The facility census was 75. The facility Administrator was notified on [DATE] at 9:00 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. […]

• Actual harm, isolatedF757Apr 3, 2025

  Licensure Reference Number 175 NAC 12.006.09 (H) Based on observation, record review, and interviews; the facility failed to ensure that one (Resident 5) of three sampled residents were not over-medicated. The facility identified a census of 89. Findings are: A record review of an undated Psychotropic Medication Use Policy revealed the following: Residents receiving psychotropic medications are monitored for adverse consequences. If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued, and document the rationale for this decision. […]

• Actual harm, isolatedF686Dec 16, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility failed to implement measures to prevent pressure ulcers for Resident 9 and to promote healing of facility acquired pressure ulcers (a pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful) for Residents 52 and 56. […]

• Actual harm, isolatedF692Dec 16, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility staff failed to implement interventions to ensure resident nutritional status was maintained including monitoring and preventing weight loss and implementing nutritional interventions to promote the healing of pressure ulcers for 3 of 12 sampled resident (Resident 52, Resident 56, and Resident 38). The facility identified a census of 85 at the time of survey. Findings are: A. Review of Resident 52's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 10/22/2021 revealed an admitted [DATE]. Resident 52 had a BIMS (Brief Interview for Mental Status) score of 6 which indicated severe cognitive impairment. […]