Monument Healthcare Stonecreek

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 25, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 40 sampled residents, the facility did not implement pressure ulcer interventions to prevent infection and new ulcers from developing. This will be cited at a harm level. Resident identifier: 3. […]

• Actual harm, isolatedF684Jan 3, 2024

  Based on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident with multiple co-morbidities who had a change in condition, was hospitalized after failure to identify the change in condition in a timely manner. The deficient practice for resident 1 was found to have occurred at a harm level. […]

• No harm, potential for more than minimal, patternF554Jun 25, 2026

  Based on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 4 out of 40 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 8, 22, 35, and 78.Findings included:1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, difficulty in walking, and muscle weakness.On 6/22/26 at 9:21 AM, a concurrent observation and interview were conducted with resident 8. On resident 8's bedside table there was a bottle of turmeric tablets and one white tablet. […]

• No harm, potential for more than minimal, patternF690Jun 25, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary. Specifically, for 3 out of 40 sampled residents, the facility did not discontinue residents' Foley catheters when there were no indications for use. Additionally, facility staff were not trained on the use of a PureWick for a resident and the PureWick tubing was observed draped over the head of the bed and not able to down drain. Resident identifiers: 3, 46, and 98.Findings included:1. […]

• No harm, potential for more than minimal, patternF775Jun 25, 2026

  Based on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 40 sampled residents, laboratory results were not located in the medical record. Resident identifiers: 4, 46, and 99.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.Resident 4's physician's orders revealed the following:a. On 5/15/26, Admit labs: CBC [complete blood count], CMP [comprehensive metabolic panel], prealbumin, Hga1c [hemoglobin A1C], TSH [thyroid stimulating hormone] one time only for 1 Day.b. […]