Monument Healthcare Millcreek

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF757Nov 20, 2025

  Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 3 out of 37 sampled residents, 2 of the residents' blood pressure medications were administered outside of the physician's ordered parameters and the third resident was not given an ordered medication as scheduled. Resident identifier: 26, 28, and 146.1. […]

• No harm, potential for more than minimal, patternF919Nov 20, 2025

  Based on observation and interview it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff area for toilet facilities. Specifically, the facility had seven public bathrooms that were accessible by residents and were not equipped with a call light system. On 11/20/25, an observation was made of the public bathroom facilities. The 300 hallway bathroom near room [ROOM NUMBER] was observed and did not contain a call light inside. The 400 hallway bathroom near the nurse's station was observed and did not contain a call light inside. The bathroom next to the staff break room was observed and did not contain a call light inside. […]

• No harm, potential for more than minimal, patternF689Nov 2, 2023

  Based on observation, interview and record review it was determined, for 8 of 22 sampled residents, that the facility did not ensure that the environment remained as free of accident hazards as was possible. Specifically, water temperatures in residents bathrooms were high. Resident identifiers: 2, 32, 33, 38, 45, 160, 307, and 309. Findings include: 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia, muscle weakness, unsteadiness on feet and delusional disorders. On 10/30/23 at 11:21 AM, an observation was made of resident 33's bathroom in room [ROOM NUMBER]. The water temperature in the hand washing sink was 122.4 degrees Fahrenheit. An interview was conducted with resident 33. […]

• No harm, potential for more than minimal, isolatedF694Jan 21, 2026

  Resident 2 was admitted to the facility on [DATE] with diagnoses which consisted of displaced bimalleolar fracture of right lower extremity, displaced avulsion fracture of right talus, chronic pulmonary edema, congestive heart failure, chronic kidney disease, kidney transplant status, unspecified protein-calorie malnutrition, fistula of the intestine, contusion of the abdominal wall, dyspnea, disorders of phosphorus metabolism, and hypokalemia. On 1/20/26 through 1/21/26 resident 2's medical records were reviewed. On 10/29/25, resident 2's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF697Jan 21, 2026

  Based on interview and record review it was determined that the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, related to pain management. Specifically 1 of 4 residents sampled, was hospitalized due to opiate toxicity. Resident Identifier: 4 Findings Included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included sepsis, obstructive and reflux uropathy, and calculus of kidney. Review of resident 4's medical record was completed on 1/21/26. On 1/1/26 at 10:47 AM, a Physician's Progress Admit Note for resident 4 revealed that a medication reconciliation was done with the patient's family and his primary care physician's records. […]