Monument Rehabilitation Care Center Inspection NE
SCOTTSBLUFF, NE - Monument Rehabilitation and Care Center received multiple citations during a federal inspection in August 2024, with violations ranging from improper medication administration to infection control failures affecting the facility's 75 residents.
Critical Medication Safety Failures
Federal inspectors documented widespread problems with medication administration that posed significant risks to residents requiring diabetes care. The facility's medication error rate reached 16 percent - more than three times the maximum allowable rate of 5 percent established by federal regulations.
The most serious concerns involved improper insulin administration techniques. Inspectors observed medication aides failing to follow established protocols when preparing insulin injections for diabetic residents. According to the facility's own procedures, staff must prime insulin pens by holding them upright and allowing a test dose to emerge from the needle tip to ensure proper function and accurate dosing.
However, during multiple observations, inspectors documented medication aides consistently holding insulin pens downward during the priming process, which can trap air bubbles and result in inaccurate insulin doses. This occurred with three separate residents receiving insulin injections on different occasions.
When staff fail to properly prime insulin pens, air bubbles can remain in the medication delivery system, potentially causing residents to receive less insulin than prescribed. For diabetic residents, receiving inadequate insulin doses can lead to dangerous blood sugar spikes, increasing risks of diabetic complications, dehydration, and in severe cases, diabetic coma.
Additionally, inspectors found problems with blood glucose testing procedures. Staff were observed using the first drop of blood from finger pricks rather than wiping it away and testing the second drop, as required by medical standards. The first drop of blood can contain tissue fluid and contaminants that may produce inaccurate readings, potentially leading to inappropriate insulin dosing decisions.
Falls Prevention System Breakdown
The inspection revealed significant failures in fall prevention protocols for a high-risk resident with multiple sclerosis, seizure disorder, and dementia. Despite experiencing six documented falls between June and July 2024, including one resulting in a head injury requiring emergency room treatment, the facility failed to properly implement ordered safety interventions.
The resident's care plan specified placement of a specialized scoop mattress designed to alert the resident to bed edges and prevent falls. However, inspectors found the resident was sleeping on a regular flat mattress instead of the prescribed safety equipment. Staff interviewed during the inspection were unaware that the special mattress had been ordered as a fall prevention measure.
Effective fall prevention in nursing homes requires a multi-layered approach including environmental modifications, appropriate assistive equipment, staff training, and continuous monitoring. When facilities fail to implement ordered interventions, residents face increased risks of serious injuries including fractures, head trauma, and other complications that can significantly impact quality of life and health outcomes.
Medication Oversight Gaps
The facility failed to ensure proper pharmacist oversight of resident medications, with one resident going six months without required monthly medication reviews. Federal regulations mandate that licensed pharmacists review each resident's complete medication regimen monthly to identify potential drug interactions, unnecessary medications, and dosing concerns.
The affected resident was receiving multiple high-risk medications including insulin, antipsychotic medications, antidepressants, and blood pressure medications. Without regular pharmacist review, dangerous drug interactions or inappropriate medication combinations can go undetected, potentially causing adverse reactions, increased fall risk, or other serious health complications.
Monthly medication reviews serve as a critical safety net in nursing home care, where residents often take multiple medications and may have changing health conditions. These reviews help ensure medications remain appropriate, effective, and safe as residents' conditions evolve.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Monument Healthcare and Nursing Center in Scottsbluff, NE was cited for violations during a health inspection on August 1, 2024.
The facility's medication error rate reached **16 percent** - more than three times the maximum allowable rate of 5 percent established by federal regulations.
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.