Monument Healthcare Pioneer Trail

In the surveyor’s words

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

• Actual harm, isolatedF690Apr 3, 2025

  Based on interview and record review, the facility failed to ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, for 1 out of 27 sampled residents, a resident was not given an oral antibiotic that was susceptible to treat her urinary tract infection (UTI) and then required intravenous (IV) antibiotics. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included obstructive and reflex uropathy, type 2 diabetes mellitus, and dementia. On 4/1/25 at 8:23 AM, an interview was attempted with resident 15. […]

• Actual harm, isolatedF600Aug 24, 2023

  Based on record review, interviews, and facility document and policy review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 (Resident #4) of 6 residents reviewed for abuse prohibition. Resident #189 touched Resident #4, a severely cognitively impaired resident, inappropriately on the breast on 10/23/2022 and the facility failed to implement adequate interventions to address Resident #189's behavior. This failure resulted in Resident #189 touching Resident #4 inappropriately on the legs, private area, and breast area on 12/26/2022. […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was expired food in the dairy refrigerator, expired food in the main refrigerator, expired food in the resident refrigerator, unlabeled and undated food in the resident refrigerator, and the facility dish machine was not testing at the required levels. Findings included: On [DATE] at 8:05 AM, an initial tour of the kitchen was completed. The following observations were made: a. There was an opened bag of whipped topping with no visible opened date. b There was an open container of parmesan cheese with a use by date of [DATE]. c. […]

• No harm, potential for more than minimal, patternF609Aug 24, 2023

  Based on record reviews, interviews, and facility document and policy review, the facility failed to report allegations of abuse within the required two-hour timeframe. This failure affected 4 of 5 total allegations of abuse reviewed by the survey team, involving 5 (Residents #4, #189, #15, #19, and #16) of 6 sampled residents reviewed for abuse concerns. On 10/22/2022 and 12/26/2022, facility staff observed Resident #189 touch Resident #4 inappropriately. The facility did not report either allegation of sexual abuse to the state survey agency. On 03/16/2023, Resident #15 alleged Resident #4 hit them, but the facility did not report the allegation of physical abuse to the state survey agency until 03/19/2023 after a second allegation was made. […]

• No harm, potential for more than minimal, isolatedF609Apr 3, 2025

  Based on interview and record review, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 27 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairments punched another resident in the back. Resident identifiers: 20 and 36. Findings included: 1. […]