Monument Healthcare Murray Creek

In the surveyor’s words

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

• Actual harm, patternF600Jun 28, 2025

  Based on interview, record review, document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal and sexual abuse by a resident. Residents #33, #71, and #351 all reported they felt threatened and/or uncomfortable around Resident #346, a resident who was know to display sexually inappropriate behaviors. The facility further failed to protect the residents' rights to be free from physical abuse by staff. On 02/14/2025, Registered Nurse (RN) #9 willfully and intentionally yanked a walker from Resident #402, which caused the resident to fall to the floor. Resident #402 sustained a 2-inch goose egg to the forehead and bruised knees. The facility substantiated that abuse occurred and terminated the employment of RN #9. […]

• Actual harm, isolatedF689Mar 31, 2026

  Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards for one of one resident reviewed for accidents (Resident #11). Specifically, the facility failed to ensure a mechanical lift sling was in safe, functional condition, resulting in a strap breakage during a transfer. This failure caused Resident #11 to fall, resulting in a 1cm scalp laceration and severe pain (9/10).The facility's noncompliance was determined to be Past Noncompliance. […]

• Actual harm, isolatedF689Jan 31, 2024

  Based on interview and record review, it was determined that the facility did not ensure that 1 out of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who was assessed as being a high risk for falls did not have interventions in place to prevent falls. The resident had a fall and sustained a maxillary fracture. Resident identifier: 3. Findings include: 1. Resident 3 was initially admitted to the facility on [DATE] and again on 9/13/23 with diagnoses which included cerebral infarction, dysphagia, ataxia, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, difficulty in walking, muscle weakness, need for assistance with personal care, atrial fibrillation, cognitive communication deficit, insomnia, nausea,… […]

• No harm, potential for more than minimal, widespreadF847Jun 28, 2025

  Based on interview, record review, and document review, the facility failed to ensure residents and/or their representatives were afforded 30 days to revoke their signed binding arbitration agreement for 3 (Residents #62, #78, and #82) of 3 sampled residents reviewed for arbitration.The facility Binding Arbitration Agreement with a copyright date of 2024, indicated 9. Revocation: This Agreement may be revoked by the Resident by written notice mailed to the Administrator of the Facility, using certified mail with return receipt requested, within ten (10) days after the date hereof, and if not revoked shall govern all aspects of the relationship between Facility and Resident upon and after the date of the Agreement.1. […]

• No harm, potential for more than minimal, widespreadF848Jun 28, 2025

  Based on interview, record review, and document review, the facility failed to ensure residents and/or their representatives were afforded an arbitration venue convenient to both parties for 3 (Residents #62, #78, and #82) of 3 sampled residents reviewed for arbitration.The facility Binding Arbitration Agreement with a copyright date of 2024, revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.1. An admission Record indicated the facility admitted Resident #62 on 05/19/2023.Resident #62's undated Binding Arbitration Agreement signed by the resident and the printed name of the Dietary Manager revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.2. […]