Monument Healthcare: Pain Management Failures - NE
Federal inspectors documented the lapse during a complaint inspection completed August 16, 2025. The resident, identified in inspection records only as Resident 90, had pain that was not being controlled. Nursing staff did not seek additional orders from the orthopedic physician overseeing the resident's care. They did not call the primary care physician either. They did not send the resident to the emergency room. The inspection record does not indicate they tried much of anything.
The Director of Nursing said she had no idea it had happened.
"The DON stated they were not aware of Resident #90's unrelieved pain," inspectors wrote, recording her words during an interview the morning of the inspection. She told inspectors the nurses should have called the orthopedic physician first. If that physician didn't respond, they should have called the primary care physician. And if neither could be reached, the resident should have been sent to the emergency room for further evaluation and pain management.
That is the protocol she described. It is not what her staff did.
The Administrator, interviewed separately the same morning, described essentially the same expectations. Nurses should follow physician orders, assess whether pain is being managed, and if it isn't, try other interventions. If those don't work, call the physician. The Administrator mentioned repositioning the resident or moving them to a different setting as options staff could try. Whatever was attempted, it should be documented.
The inspection record does not reflect that any of that happened for Resident 90.
The violation was tagged under F0697, which covers the management of pain and the obligation to ensure residents receive treatment and care for pain that is identified. Inspectors rated the harm level as minimal harm or potential for actual harm, and noted that few residents were affected.
That classification, minimal harm, is a regulatory designation. What it means in practice is that inspectors determined the harm had not yet risen to a more severe level, not that the resident was comfortable, and not that the failure was minor. A person in a nursing home, dependent on staff to manage their pain, told someone their medication wasn't working. The people responsible for their care did not escalate. The people who run the facility did not know.
The gap between what the Director of Nursing described as standard practice and what actually happened to Resident 90 is the finding. She laid out a clear chain of responsibility during her interview. Call the orthopedic doctor. If no response, call primary care. If still no resolution, send the resident for emergency evaluation. She said it plainly, as if it were obvious, because in a functioning system it would be.
Resident 90's pain went unrelieved anyway.
Monument Healthcare and Nursing Center is located in Scottsbluff in western Nebraska. The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, raised a concern that prompted regulators to investigate. The inspection report does not say who filed the complaint or what specifically prompted it.
What it does say is that when inspectors arrived and began asking questions, the facility's own leadership confirmed the breakdown. The Administrator and the Director of Nursing both described, in separate interviews, what nurses are supposed to do when a resident's pain is not controlled. Neither described it as a new or complicated expectation. Both treated it as basic.
The record of what nursing staff actually did for Resident 90 did not match what either of them said.
Pain in nursing home residents, particularly those under orthopedic care, is not a peripheral concern. It affects sleep, mobility, mood, and the ability to participate in rehabilitation. Unrelieved pain can accelerate physical decline. For a resident already requiring orthopedic oversight, it is among the most direct signals that something is wrong and that the care plan needs to change.
The nurses who cared for Resident 90 knew the pain was not being managed. The inspection record makes that clear. What they did not do was tell anyone with the authority to change it.
Resident 90's name does not appear in the public record. What happened to them after the inspection, whether their pain was eventually addressed, whether they remained at the facility, is not documented in the materials inspectors released. The record ends with two administrators describing, in careful detail, exactly what should have been done, and an inspector's note that it wasn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Healthcare and Nursing Center from 2025-08-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Monument Healthcare and Nursing Center in Scottsbluff, NE was cited for violations during a health inspection on August 16, 2025.
Federal inspectors documented the lapse during a complaint inspection completed August 16, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.