Monument Hill Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Sep 11, 2021

  Based on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to investigate to determine the causative factors of falls to help prevent and/or reduce risk for falls and implement new fall interventions, if needed; and failed to ensure fall interventions were implemented to help prevent falls. This affected three (3) of three (3) residents reviewed for falls (Resident #1, Resident #3, and Resident #10), The facility also failed to complete post-fall neurological checks for one (1) of three (3) residents reviewed for falls (Resident #3). […]

• Immediate jeopardy, isolatedF689Jul 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 04/08/2025, Resident #1 eloped from the facility through a side door and was later found by a neighbor in a grassy area approximately 219 feet away from the facility. This failure placed the resident at risk for serious harm.The non-compliance was identified as past non-compliance. The immediate jeopardy began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance prior to the start of the survey. […]

• No harm, potential for more than minimal, widespreadF812Apr 22, 2022

  Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: 1. Over the kitchen sink had no paper towels to dry hands. 2. Kitchen refrigerator cooler had unlabeled, opened expired food items. 3. Four 5-gallon containers of water was left on the floor. 4. kitchen counter had items not sealed and not covered. 5. During pureed food items, Cook K used the robot coupe and did not wash and sanitize between food items. This could affect and cause resident to be sick when eating food from the kitchen. The Findings were: Observations in kitchen: Observation on [DATE] beginning at 10:02 a.m. […]

• No harm, potential for more than minimal, patternF760Aug 6, 2026

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 2 residents (Resident #3) reviewed for medication errors. The facility failed to ensure nursing staff administered 7 doses of Rytary Oral Capsule Extended Release 48.75-195MG and Rytary Oral Capsule Extended Release 61.25-245 MG (Carbidopa-Levodopa) at the scheduled time for Resident #3. These failures could place residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications. […]

• No harm, potential for more than minimal, patternF755Jul 9, 2026

  Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; for all medication carts reviewed for controlled drug reconciliation. The facility failed to ensure they stored and labeled 34 tablets of 5-325 Norco for Resident #1 13 tablets of 5-325 for Resident #2 and 2 tablets of Oxycodone 5mg for Resident #3. This failure could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications.Findings included: Record review of facility self-report dated [DATE] reflected on [DATE] the facility conducted a narcotics count audit for discontinued medication. […]