Monument Healthcare Millcreek

Inspectors wroteResident 2 was admitted to the facility on [DATE] with diagnoses which consisted of displaced bimalleolar fracture of right lower extremity, displaced avulsion fracture of right talus, chronic pulmonary edema, congestive heart failure, chronic kidney disease, kidney transplant status, unspecified protein-calorie malnutrition, fistula of the intestine, contusion of the abdominal wall, dyspnea, disorders of phosphorus metabolism, and hypokalemia. On 1/20/26 through 1/21/26 resident 2's medical records were reviewed. On 10/29/25, resident 2's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. On 10/24/25, resident 2's physician ordered TPN 1600 milliliter (ml) to run continuously in the evening per the pharmacy instructions. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, related to pain management. Specifically 1 of 4 residents sampled, was hospitalized due to opiate toxicity. Resident Identifier: 4 Findings Included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included sepsis, obstructive and reflux uropathy, and calculus of kidney. Review of resident 4's medical record was completed on 1/21/26. On 1/1/26 at 10:47 AM, a Physician's Progress Admit Note for resident 4 revealed that a medication reconciliation was done with the patient's family and his primary care physician's records. Morphine tablets (immediate release, 7.5 milligrams (mg) every 6 hours as needed), were ordered for resident 4's dorsalgia. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 3 out of 37 sampled residents, 2 of the residents' blood pressure medications were administered outside of the physician's ordered parameters and the third resident was not given an ordered medication as scheduled. Resident identifier: 26, 28, and 146.1. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, hypertensive chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and atrial fibrillation. [...]

Inspectors wroteBased on observation and interview it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff area for toilet facilities. Specifically, the facility had seven public bathrooms that were accessible by residents and were not equipped with a call light system. On 11/20/25, an observation was made of the public bathroom facilities. The 300 hallway bathroom near room [ROOM NUMBER] was observed and did not contain a call light inside. The 400 hallway bathroom near the nurse's station was observed and did not contain a call light inside. The bathroom next to the staff break room was observed and did not contain a call light inside. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 37 sampled residents, that the facility did not immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the physician was not notified when a resident's Trulicity was held. Resident identifiers: 28.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, a resident was admitted with wounds and dressings on their bilateral feet and did not have wound care orders initiated until 9 days after admission. Resident identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 9:07 AM, an interview was conducted with resident 117. Resident 117 stated that he had both ankles surgically cleaned out and the left foot had MRSA. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not ensure that the resident was free from any significant medication errors. Specifically, multiple doses of Vancomycin were omitted from the residents scheduled medication administration. Resident identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. Resident 117 stated that he had a Peripherally Inserted Central Catheter (PICC) line in his right arm and had multiple daily doses of intravenous antibiotics. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 37 residents sampled, that the facility did not notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of the clinical reference ranges. Specifically, a resident's Vancomycin trough levels were high and the Medical Doctor (MD) was not notified of those high values. Resident identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 37 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological and other diagnostic services. Specifically, a resident 21's Kidney, Ureter, and Bladder (KUB) was not in the medical records. Resident identifier 21. Resident 21 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder. Review of resident 21's medical record was completed on 11/17/25 through 11/20/25. On 11/2/25, a physician's order documented an immediate (STAT) KUB radiograph (x-ray). On 11/2/25 at 12:48 pm, a nursing progress alert note stated the following: The patient decided to stay in bed all day today. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 37 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident was not placed on proper contact precautions. Resident Identifier: 117. Resident 117 was admitted to the facility on [DATE] with diagnoses which included arthritis due to bacteria of left ankle and foot, gout, Methicillin-resistant Staphylococcus aureus (MRSA), diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. On 11/18/25 at 8:55 AM, an interview was conducted with resident 117. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 22 sampled residents, that the facility did not ensure that the environment remained as free of accident hazards as was possible. Specifically, water temperatures in residents bathrooms were high. Resident identifiers: 2, 32, 33, 38, 45, 160, 307, and 309.

Inspectors wroteBased on observation and interview it was determined, for 3 of 22 sampled residents, that the facility failed to maintain a safe, clean, comfortable and homelike environment. Specifically, the water pressure and temperature of a shared bathroom sink was low. Resident identifiers:

Inspectors wroteBased on record review and interview, for 1 of 22 sampled residents, the facility did not ensure that the Preadmission Screening for individuals with a mental health disorder was performed by a person or entity other than the State Mental Health Authority prior to admission, and that because of the physical and mental condition of the individual, the individual required the level of services provided by the nursing facility, and whether the individual required specialized services. Specifically, a resident admitted with a mental health disorder did not have a Preadmission Screening Resident Review (PASRR) Level II recommended or completed. Resident identifier: 51.

Inspectors wroteBased on observation, interview, and record review, for 1 of 22 sampled residents, the facility did not provide the necessary services to maintain good nutrition, grooming, and persona and oral hygiene for residents who were unable to carry out the activities of daily living. Specifically, a resident was not showered twice weekly according to his preferences. Resident Identifier: 158. Findings Include: Resident 158 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, muscle weakness, type 2 diabetes, acute kidney failure and major depressive disorder. On 10/30/23 at 10:18 AM, an interview was conducted with resident 158. Resident 158 stated he had only received one shower since his admission. Resident 158 stated he had not been offered a shower the day after he arrived. [...]

Inspectors wroteBased on interview and record review it was determined, for 2 of 22 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist and any irregularities were reported to the physician and were acted upon. Specifically, monthly pharmacy reviews identified irregularities that had not been implemented. Resident identifiers: 2 and 8.

Inspectors wroteBased on interview and record review it was determined, for 1 of 22 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a resident was administered double the dose of physician prescribed Lasix. In addition, the resident had an elevated potassium level prior to being administered double to dose of lasix and there was no physician follow-up documented. Resident identifier: 8.