Monument Healthcare and Nursing Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S) Based on observation, interview, and record review; the facility failed to contain 4 (Residents 3, 6, 7, and 8) of 4 sampled residents' catheter bags within a dignity bag while in view of others. The facility identified a census of 82. Findings Are: A record review of facility policy Dignity with a revision date of February 2021 revealed demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by helping the resident keep urinary catheter bags covered. A.A record review of Resident 3's admission Record dated 6/8/2026 revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, the facility failed to ensure garbage and refuse were stored in a covered receptacle. In addition, the facility failed to ensure malodorous trash bags, debris, and supplies were not on the ground around the garbage and refuse receptacle. These failures created the potential for pest activity and had the potential to affect all residents residing in the facility.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and facility document and policy review, the facility failed to ensure: 1. cold foods were maintained at 41 degrees Fahrenheit (F) or below during meal service; 2. cartons of milk were labeled with an expiration date; 3. food items were labeled with use-by-dates (UBDs); 4. expired food items were discarded; and 5. frozen food items were stored in sealed containers and off the freezer floor. These failures had the potential to affect all residents receiving meals from the dietary department.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to provide a written notice of bed hold policies upon transferring a resident to a hospital and failed to send a copy of a notification of transfer/discharge to the Ombudsman for 1 (Resident #86) of 1 resident reviewed for hospitalizations.

Inspectors wroteBased on observation, interview, record review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) for 5 (Residents #2, #5, #35, #37 and #76) of 8 residents reviewed for Preadmission Screening and Record Review (PASRR) requirements, smoking, unnecessary medications, or speech/communication concerns.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to implement an adequate pain management program by accurately assessing, monitoring, and treating pain, which affected 1 (Resident #90) of 3 residents reviewed for pain management. The failure resulted in Resident #90 experiencing uncontrolled pain.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and facility document review, the facility failed to ensure that in the absence of a full-time registered dietitian (RD) or other clinically qualified nutrition professional, a qualified individual was designated to serve as the director of food and nutrition services. This had the potential to affect all residents receiving meals from the dietary department.

Inspectors wroteBased on interview, record review, facility document, and facility policy review, the facility failed to ensure a complete and accurate medical record for 2 (Resident #76 and Resident #48) of 18 sampled residents.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used the proper personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBP) for 1 (Resident #48) of 1 resident observed for wound care.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and facility document and policy review, the facility failed to consistently employ a qualified infection preventionist. The facility's failure to employ a qualified infection preventionist to be responsible for the infection prevention and control program had the potential to affect all 78 residents residing in the facility.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, facility document review, and facility policy review, the facility failed to post notice of the availability of the most recent survey results in a prominent and accessible area for the public; failed to post the most recent survey results in a location that was readily accessible to residents and visitors; and failed to maintain reports with respect to any surveys, certifications, and complaint investigations from the preceding three years and have them available for any individual to review upon request. The deficiency affected 10 (Residents #1, #6, #15, #24, #28, #29, #63, #67, #80, and #83) of 10 residents interviewed during a Resident Council meeting and had the potential to affect all the residents in the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) State Statute 28-372 Based on record review and interview, the facility failed to submit an investigative report to the State Agency within 5 working days following a fall that resulted in significant injury for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 88.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 (H) Based on observation, record review, and interviews; the facility failed to ensure that one (Resident 5) of three sampled residents were not over-medicated. The facility identified a census of 89.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 (I)(i)(1) Based on record review and interview, the facility failed to notify the resident and/or the residents' representative of a new medication for one (Resident 5) of three sampled residents. The facility identified a census of 89.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 (F) Based on observation, record review, and interviews, the facility failed to have resident specific interventions in place to address or minimize the behaviors of one (Resident 1) of three sampled residents. The facility identified a census of 89.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 Based on interviews and record review, the facility failed to perform wound care as ordered for one (Resident 6) of three sampled residents. The facility identified a census of 89.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 (F) (i) (5) Based on observation, record review, and interviews, the facility failed to protect other residents from one (Resident 1) of three sampled residents who displayed adverse behaviors. The facility identified a census of 89.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 (H) Based on record review and interview, the facility failed to have a diagnosis in place to support the use of an antipsychotic medication and failed to ensure an as needed antipsychotic medication order was limited to 14 days as required. This affected 1 (Resident 5) of 3 sampled residents. The facility census was 89.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to perform wound care according to the provider's order for 1 (Resident 7) of 3 sampled residents. The facility census was 83. Findings Are: A record review of Resident 7's admission record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of an open wound to their right shoulder which was added on 4/18/2022. A record review of Resident 7's physician's order revealed the following wound care order with a start date of 8/18/24: -Wound care to right shoulder: cleanse with Normal Saline (NS)/wound cleanser and gauze, do not allow site to close, apply No-Sting barrier film to peri-wound, apply Dermablue/equivalent over wound opening, and cover with a silicone border dressing. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(D). Based on observation, interview, and record review; the facility failed to prevent the potential for cross contamination during wound care for 1 (Resident 7) of 3 sampled residents. The facility census was 83. Findings Are: A record review of facility policy Wound Care dated October 2010 revealed in the section Steps in the Procedure, staff were to use a disposable cloth to establish clean field on resident's overbed table and were to place all items to be used during procedure on the clean field. The policy stated staff were to wash and dry their hands after placing supplies on the overbed table, after removing the soiled dressing from the resident, and after the completion of performing the wound care. The policy also revealed staff were to wear sterile gloves when physically touching the wound or holding a moist surface over the wound. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record reviews and interviews; the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for three residents (Residents 40, 32 and 46). The facility census was 75. The facility Administrator was notified on [DATE] at 9:00 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification.

Inspectors wroteLicense Reference Number 175 NAC 12-006.19(A) Based on observations and interviews: the facility staff failed to ensure the facility dishwashing machine reached the required temperature to prevent to the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility staff identified a census of 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(ii) Licensure Reference Number 175 NAC 1-005.06 (A)(D)(F) Based on record review and interview the facility failed to ensure that pre-employment health history screens were reviewed to prevent the potential for transmission of contagious disease for 5 of 5 staff; the facility failed to ensure multi-use equipment was sanitized between use and hand hygiene practices were followed between tray passes; and the facility failed to implement a facility water management plan for the prevention of waterborne illnesses. The facility census was 75.

Inspectors wroteLicense Reference Numbers 175 NAC 12-006.19, NAC 1-006.02 Based on record reviews, observations and interviews, the facility failed to provide a clean, home like environment and to ensure equipment and building fixtures were in good, working order. This had the potential to effect all of the residents residing in the facility. The facility stated census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview the facility failed to ensure that a written summary of the baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed with the resident/resident representative and that the resident/resident representative was provided a copy of the written summary of the baseline care plan for 4 of 4 residents reviewed (Residents 22, 127, 23, and 13). This had the potential to prevent the resident/resident representative from identifying and communicating additional care required for the resident. The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review, and interview the facility failed to ensure that staff performed blood glucose testing (determining the amount of blood sugar in your blood) in a manner consistent with current professional standards to prevent errors for 5 of 7 residents (Residents 47, 40, 48, 21, and 1). The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to maintain a medication error rate of less than 5% with an observed medication error rate of 16% (25 medications administered with 4 errors). The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (E) Based on interviews and record reviews, the facility failed to provide bathing preferences for 1 (Resident 27) of 1 sampled resident. The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observation, record review and interview the facility failed to investigate falls for causative factors and implement interventions by causative factors to prevent falls with injury for 1 Resident, (Resident #24) of 2 sampled residents. Facility stated census of 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview the facility failed to ensure a monthly medication review (MRR) (a monthly review of a resident's medications by a licensed pharmacist to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary drugs) was performed for 1 resident (Resident 37) of 5 residents reviewed. This had the potential for significant medication irregularities to go unidentified. The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview the facility failed to ensure as needed antipsychotic medications were limited to 14 days of use and residents and or their representatives were informed of risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. This effected 1 of 2 sampled residents, Resident #24. Facility stated census of 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure that staff provided the ordered dose of insulin (a medication used to reduce the amount of blood sugar in the blood of residents with diabetes) to residents to prevent significant medication errors for 3 of 4 residents observed (Residents 40, 48, and 16). The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-009.04 Based on observation and interview the facility failed to maintain a pest free environment. This had the potential to effect all of the residents residing in the facility. The facility stated a census of 75.

Inspectors wroteLicensure Reference Number 175NAC 12-006.04A(iii) Based on record review and interview the facility failed to ensure that background checks were completed prior to staff working in the facility for 1 of 5 sampled staff. This had the potential to expose all facility residents to potential abuse and neglect. The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)2 Based on observation, record review, and interview the facility failed to ensure that staff received training and assessments of competency for obtaining resident blood glucose (a measurement of the amount of blood sugar in your blood) and for use of the insulin pen (an injection device that allows you to deliver preloaded insulin-a medication used to reduce the amount of blood sugar in the blood of residents with diabetes) for 3 of 3 staff observed. This caused the residents to experience potential inaccurate blood sugar readings and incorrect insulin doses. The facility census was 75.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02 (8) Based on record review and interview; the facility failed to report to the State Agency (SA) a fall that resulted in an injury for one (Resident 4) resident within the required timeframes, and failed to thoroughly investigate allegations of residents' reporting missing funds for two (Resident 1 and Residnet 2) of three sampled residents. The facility identified a census of 87 residents at the time of the survey.

Inspectors wroteLicense Reference Number NAC 175 12-006.11E Based on observations, interviews, and record review, the facility staff failed to ensure the food services areas were maintained in a clean manor and in good repair, failed to utilize handwashing and gloving techniques during food preparation services to prevent the potential for food borne illness. This had the potential to affect 86 out of 87 residents who resided at the facility. The facility identified a census of 87 residents at the time of the survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.16E Based on interview and record review, the facility staff failed to covey the resident's personal funds within 30 days of discharge. This affected 1(Resident 188) of 3 discharged financial record reviewed. The facility identified a census of 87 at the time of survey.

Inspectors wroteBased on record review and interview, the facility failed to provide advance notifications of changes in coverage for Residents 3 and 11 on discharge from Medicare A services. This affected 2 of 3 residents sampled for Beneficiary Notification Review. The facility census was 87.

Inspectors wroteLicensure Reference Number: 175NAC 12-006.06A Based on interview and record review, the facility staff failed to display the process for submitting grievances in the facility and educating the residents how to file grievances. This had the potential to affect all of the facility residents. The facility identified a census of 87 at the time of surrey.

Inspectors wroteLicensure Reference 175 NAC 12-006.09B1(2) Based on record review and interview, the facility failed to complete a Significant Change of Status Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) for Resident 5 after admission to hospice services. This affected 1 of 1 resident sampled for hospice services. The facility census was 87.

Inspectors wroteLicensure Reference 175 NAC 12-006.09B Based on record reviews and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding a Pressure Injury for Resident 4, and a Pre-admission Screening and Resident Review [PASARR-a federal requirement to help ensure that residents are not inappropriately placed in nursing homes for long term care. Level II screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to IDD (RC) as defined by state or federal guidelines] for Resident 12. This affected 2 of 21 residents reviewed for MDS accuracy. The facility census was 87.

Inspectors wroteLICENSURE REFERENCE NUMBER 12-006.14 Based on observation, interview and record review: the facility failed to provide dental services for 1 (Resident 15) of 1 sampled resident. The facility staff identified a census of 87 at the time of the survey.

Inspectors wroteLicensure Reference 175 NAC 12-006.04 A3d Based on record reviews and interviews, the facility failed to ensure the Nebraska Nurse Aide Registry was checked prior to employees beginning to work in the facility. This affected 5 of 5 employees sampled for Registry checks and had the potential to affect all residents. The facility census was 87.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Social Services Director (SSD) had the required qualifications to hold that position in a facility with over 120 licensed beds. This had the potential to affect all residents. The facility census was 87.