Health Inspection

Monument Rehabilitation And Care Center

Inspection Date: August 1, 2024

Total Violations 1

Facility ID 285095

Location SCOTTSBLUFF, NE

Inspection Findings

F-Tag F678

Harm Level: Immediate

Residents Affected: Few the Nursing Home Administrator on [DATE] and approved on [DATE] at 11:10 PM revealed the following:

F-F678 Cardiopulmonary Resuscitation dated [DATE REDACTED] submitted by Residents Affected - Few the Nursing Home Administrator on [DATE REDACTED] and approved on [DATE REDACTED] at 11:10 PM revealed the following:

Residents identified that were affected or were identified at risk of serious injury, harm, impairment, or death were:

Resident 40, Resident 32, Resident 46

-All residents' signed code status forms will be audited starting [DATE REDACTED] to ensure physician orders match resident preferences.

-Code status spreadsheet will be updated starting [DATE REDACTED] to reflect accurate and current code statuses for each resident.

-Starting [DATE REDACTED], Social Services will contact residents without current code status preferences and discuss resident or representative wishes related to code status.

-Starting [DATE REDACTED], the Admissions Department will verify and obtain code statuses prior to admission with responsible party.

-Starting [DATE REDACTED], current code status forms will be placed in the code status binder and placed inside crash cart.

-Director of Nursing (DON) will start in-services on [DATE REDACTED] regarding:

-Code status policy

-Code status spreadsheet

-Code status form: DNR/Full Code/Do Not Hospitalize (DNH)

-Identifying a resident's code status

-Education will be provided to all staff currently on duty and prior to any staff coming off duty.

-Resident profile and code status icon on PCC will be audited and updated with current resident wishes related to code status by Unit Managers or designee weekly or upon admission or re-admit.

-Starting [DATE REDACTED], Social Services will audit code status book weekly to ensure code statuses for residents are accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 -Starting [DATE REDACTED], Admissions Department will audit code status forms received and obtained from hospital records weekly for new residents. Level of Harm - Immediate jeopardy to resident health or -Starting [DATE REDACTED], new admissions will be reviewed during clinical meetings to discuss and determine resident safety code statuses.

Residents Affected - Few -Auditing results will be submitted to Quality Assurance and Performance Improvement (QAPI) (a data driven and proactive approach to quality improvement) and addressed as appropriate.

At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on

observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.

At the time of exit, the severity of the deficiency was lowered to the D level.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41938 potential for actual harm Licensure Reference Number 175 NAC 12-006.09(H) Residents Affected - Some 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.

Findings are:

Record review of the facility procedure titled Measuring A Blood Glucose Using A Handheld Glucometer (a medical device used to measure and display the amount of sugar in the blood for residents with diabetes) dated 7/11/24 revealed the steps included: wipe the site with an antiseptic wipe. Insert the test strip into the machine (glucometer). Perform a capillary puncture (a skin prick) using a lancet (a small sterile blade used to obtain a small amount of blood for testing). Discard lancet immediately in a sharp's container. Wipe away the first drop of blood. Touch the drop of blood to the reagent (test) strip, allowing it to be taken up by the strip. Read the digital result. Provide the patient with a cotton ball or gauze to hold pressure to stop the bleeding.

Record review of the Admission Record dated 8/1/24 for Resident 47 revealed Resident 47 admitted into the facility on [DATE REDACTED]. Resident 47 had a diagnosis of Diabetes.

Observation on 7/30/24 at 3:58 PM at the medication cart on the facility 200 hall revealed Medication Aide-I (MA-I) performed hand sanitization and put on gloves. MA-I obtained the glucometer, test strip, alcohol antiseptic prep pad, and lancet and went to the room of Resident 47. MA-I wiped the fingertip of the resident's left little finger with the alcohol prep pad. MA-I pricked the finger with the lancet and squeezed the finger to force a drop of blood to appear. MA-I applied the drop to the glucometer test strip. (MA-I did not wipe away the first drop of blood and obtain a second drop of blood to test as required). MA-I told the resident the blood sugar result of 130. MA-I applied a cotton ball to the fingertip. MA-I returned to the medication cart and revealed it is too early for Resident 47's insulin.

Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a patient at a facility by a health care professional) dated 7/31/24 for Resident 47 revealed that Resident 47 had an order for sliding scale insulin (a progressive increase in the insulin dose based on

the resident's blood sugar level that is based on pre-defined blood sugar ranges as ordered by the physician). The MAR revealed that MA-I documented the blood sugar reading of 130 for the 7/30/24 blood sugar ordered for 5:30 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Interview on 8/1/24 at 9:14 AM with the facility Director of Nursing (DON) confirmed that the expectation for obtaining blood sugar using the handheld glucometer is that staff follow the procedure. The DON confirmed Level of Harm - Minimal harm or that the expectation is that staff wipe away the first drop of blood and obtain a second drop of blood to be potential for actual harm applied to the test strip. The DON confirmed that an inaccurate blood sugar reading may be obtained when

the first drop of blood is tested . The DON confirmed that using the second drop of blood for testing ensures Residents Affected - Some an accurate blood sugar reading.

Record review of the Admission Record dated 7/31/24 for Resident 40 revealed that Resident 40 admitted into the facility on [DATE REDACTED]. Resident 40 had a diagnosis of Diabetes.

Record review of the MAR dated 7/31/24 for Resident 40 revealed that Resident 40 had an order for sliding scale insulin. The MAR revealed that MA-I documented the blood sugar reading of 277 for the 7/30/24 blood sugar ordered for 4:30 PM.

Record review of the Admission Record dated 8/1/24 for Resident 48 revealed that Resident 48 admitted into

the facility on [DATE REDACTED]. Resident 48 had a diagnosis of Diabetes.

Observation on 7/30/24 at 4:12 PM at a medication cart on the 200 hall revealed that Medication Aide-J (MA-J) put on gloves and prepared supplies to check the blood sugar for Resident 48. MA-J went to the room of Resident 48 and wiped the pad of the resident's left little finger with the alcohol prep pad. MA-J pricked the finger with the lancet and squeezed until a drop of blood appeared. MA-J applied the drop to the glucometer test strip. (MA-J did not wipe away the first drop of blood and obtain a second drop of blood to test as required). MA-J revealed a blood sugar result of 153. MA-J returned to the medication cart and documented the blood sugar of 153.

Record review of the MAR dated 7/31/24 for Resident 48 revealed that Resident 48 had an order for sliding scale insulin. The MAR revealed that MA-J documented the blood sugar reading of 153 for the 7/30/24 blood sugar ordered for 5:30 PM.

Interview on 8/1/24 at 2:12 PM with MA-J revealed that MA-J was provided training on using the handheld glucometer last winter. MA-J revealed that the steps MA-J uses for obtaining a blood sugar are to identify which finger will be used and to wipe the finger with an alcohol wipe. MA-J revealed that they then poke the finger and apply the drop of blood to the test strip. MA-J revealed it is okay to use the first drop of blood.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Record review of the Admission Record dated 8/1/24 for Resident 21 revealed that Resident 21 admitted into

the facility on [DATE REDACTED]. Resident 21 had a diagnosis of Diabetes. Level of Harm - Minimal harm or potential for actual harm Observation on 7/30/24 at 4:15 PM at a medication cart on the 200 hall revealed that MA-J gathered supplies to check the blood sugar for Resident 21. MA-J put on gloves and wiped the resident's right ring finger. MA-J Residents Affected - Some wiped the pad of the resident's finger with an alcohol prep pad. MA-J pricked the pad of the finger with the lancet and squeezed the finger to produce a drop of blood. MA-J applied the drop of blood to the glucometer test strip. (MA-J did not wipe away the first drop of blood and obtain a second drop of blood to test as required). MA-J placed a cotton ball on the resident's finger. MA-J revealed a blood sugar result of 141.

Record review of the MAR dated 7/31/24 for Resident 21 revealed that Resident 21 had an order for blood glucose check before meals. The MAR revealed that MA-J documented the blood sugar reading of 141 for

the 7/30/24 blood sugar check ordered for 5:30 PM.

Record review of the Admission Record dated 8/1/24 for Resident 1 revealed that Resident 1 admitted into

the facility on [DATE REDACTED]. Resident 1 had a diagnosis of Diabetes.

Observation on 7/31/24 at 4:21 PM in the room of Resident 1 revealed that Medication Aide-K (MA-K) put on gloves and placed a glucometer test strip in the glucometer. MA-K wiped the pad of the resident's right middle finger with an alcohol prep pad. MA-K pricked the finger with a lancet. A drop of blood appeared. MA-K applied the drop of blood to the test strip. (MA-K did not wipe away the first drop of blood and obtain a second drop of blood to test as required). MA-K revealed a blood sugar result of 163.

Record review of the MAR dated 8/1/24 for Resident 1 revealed that Resident 1 had an order for sliding scale insulin. The MAR revealed that MA-K documented the blood sugar reading of 163 for the 7/31/24 blood sugar check ordered for 4:30 PM.

Interview on 8/1/24 at 1:32 PM with MA-K revealed that the facility provided training on use of the handheld glucometer and thinks it was last fall. MA-K revealed that the process for obtaining a blood sugar using the glucometer included wiping the finger with the alcohol prep pad and poking the finger. MA-K revealed they apply the drop of blood to the glucometer test strip. MA-K confirmed that MA-K was not aware that the first drop of blood was to be wiped away and the second drop of blood was to be applied to the test strip.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 49382

Residents Affected - Few Licensure 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.

Findings are:

Review of a facility policy titled Falls Management dated 05/2017 revealed the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence.

A review of an Admission Record dated 07/30/2024 revealed the facility admitted Resident #24 on 01/12/2024 with diagnoses that included Multiple Sclerosis (a disease of the central nervous system), generalized muscle weakness, seizure disorder (when nerve cells don't signal properly causing seizures), and dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

Review of a facility supplied document titled with the facility name and Incidents by Incident type dated 07/29/2024 revealed Resident #24 had unwitnessed falls on 06/07/2024, 06/13/2024, 06/20/2024, 07/03/2024, 07/11/2024, and 07/21/2024.

The Quarterly Minimum Data Set (MDS) (a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) dated 07/19/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 4 indicating the resident was severely cognitively impaired. The resident was independent with eating, needed partial to moderate assistance with bed mobility and was dependent on staff assistance for toilet use and transfers. Resident #24 used a wheelchair for mobility propelled by staff and was frequently incontinent of bladder and continent of bowel. The resident was coded to have had two or more falls without injury in the last 90 days.

Review of Resident #24's Care Plan with the following dates revealed the resident was at risk for falls with interventions listed as:

-06/07/2024 A scoop mattress was placed on the resident's bed to alert the resident to the edge of their bed for safety.

-07/21/2024 A fall mat is to be placed on the floor beside the resident's bed to prevent injuries when the resident places themselves on the floor during seizure and behavior activity episodes. Staff are to follow the provider recommendations and a medication review with medication changes occurred. The residents' room was moved closer to the nurse's station for closer observation.

Record review of facility supplied Un-Witnessed Fall report dated revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -06/07/2024 Resident #24 was found sitting on the floor with their back against their bed. The resident confirmed that they had sled off the edge of the bed. There were no documented injuries to the resident. Level of Harm - Minimal harm or potential for actual harm -07/21/2024 Resident #24 was found on the floor next to their bed. The resident received a hematoma and laceration requiring sutures in the local emergency room . Residents Affected - Few

In an observation on 07/29/2024 at 3:15 PM revealed Resident #24's bed had a regular flat mattress present.

In an interview on 07/30/2024 at 10:15 AM with Medication Aide D (MA-D), MA-D revealed fall prevention interventions for Resident #24 was to keep the resident in close observation and redirect the resident when attempting to get out of their wheelchair. MA-D further reported Resident #24 was recently moved closer to

the nurse's station for closer observation while in their room.

In an observation on 07/31/2024 at 1:15 PM it was observed that Resident #24's bed was placed with the head of the bed against the wall with a fall mat placed on the floor to the left side of the bed and Resident #24 had a regular flat mattress present.

In an interview on 07/31/2024 at 1:30 PM with Licensed Practical Nurse (LPN) B, LPN-B confirmed that Resident #24 mattress was a regular flat mattress. LPN-B denied knowing if the resident was to have a special or scoop mattress.

In an interview on 07/31/2024 at 2:45 PM with the Assistant Director of Nursing (ADON), the ADON confirmed that the resident was to have a special scoop mattress to their bed as a fall prevention intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41938

Residents Affected - Few Licensure 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.

Findings are:

Record review of the Admission Record for Resident 37 dated 7/30/24 revealed that Resident 37 admitted into the facility on [DATE REDACTED]. Diagnoses included Diabetes, hypertension (high blood pressure), and major depressive disorder.

Record review of the Care Plan dated 7/30/24 for Resident 37 revealed that Resident 37 is on diuretic therapy (treatment with medicines that help reduce fluid buildup in the body. They are sometimes called water pills). The Care Plan revealed that the diuretic therapy may cause dizziness, hypotension (low blood pressure), fatigue, and increased risk for falls. The Care Plan revealed that Resident 37 has Diabetes. Interventions included diabetes medication as ordered by doctor. Monitor for side effects. The Care Plan revealed that Resident 37 has a potential behavior problem related to depression. Interventions included administer medications as ordered and monitor for side effects. The Care Plan revealed that the physician increased the resident's antipsychotic medication (a psychotropic medication used to manage psychotic disorders) due to increased anxiety on 12/12/23. The Care Plan revealed that Resident 37 has altered cardiovascular status (heart or blood vessel issues). Interventions included to give all cardiac medications as ordered and observe and document side effects. Report adverse reactions to the physician.

Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 5/23/24 for Resident 37 revealed that Resident 37 received insulin all 7 days of the 7 day lookback period. The MDS revealed that Resident 37 received antipsychotic, antianxiety, antidepressant, and antiplatelet (medications that prevent platelets in the blood from sticking together and forming blood clots) medications during the 7 day lookback period.

Record review of the Monthly Regimen Reviews (monthly medication reviews) completed for Resident 37 revealed that MRRs were completed on:

7/31/23- with no changes required to the resident medications.

8/29/23- with note that the resident Medication Administration Record update recommended.

3/31/23- no recommendations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 4/29/24- with note that Paxil (an antidepressant psychotropic medication) used for anxiety but not linked to a diagnosis code. Level of Harm - Minimal harm or potential for actual harm 5/30/24- no recommendations.

Residents Affected - Few 6/30/24- consider gradual dose reduction for Paxil, aripiprazole (an antipsychotic medication used to treat schizophrenia, bipolar disorder, depression), lorazepam (a psychotropic medication used to treat anxiety), and mirtazapine (a psychotropic antidepressant).

Record review of the medical record for Resident 37 revealed no MRRs for 9/2023, 10/2023, 11/2023, 12/2023, 1/2024, or 2/2024.

Interview on 7/31/24 at 2:06 PM with the facility Infection Control Coordinator (ICC) revealed that the ICC is responsible for follow up on the resident MRRs. The ICC confirmed that an MRR is to be performed monthly for every resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm 49382 Residents Affected - Few Licensure 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.

Findings are:

A review of a facility policy titled Antipsychotic Medication Use and dated 07/2022 revealed:

-Residents and or resident representatives will be informed of the recommendation, risks, benefits, purpose, and potential adverse consequence of antipsychotic medication use.

-As needed orders for antipsychotic medications will not be renewed beyond 14 days. The duration of the as needed order will be indicated in the order for the medication.

A review of an Admission Record dated 07/30/2024 revealed the facility admitted Resident #24 on 01/12/2024 with diagnoses of Multiple Sclerosis (a disease of the central nervous system), generalized muscle weakness, seizure disorder (when nerve cells don't signal properly causing seizures), and dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

The Quarterly Minimum Data Set (MDS) (a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning) dated 07/19/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 4 indicating the resident was severely cognitively impaired. The resident was coded as displaying inattention and disorganized thinking that fluctuated in frequency and severity and not displaying any behaviors. Resident #24 was independent with eating, needed partial to moderate assistance with bed mobility and was dependent on staff assistance for toilet use and transfers. Resident #24 used a wheelchair for mobility propelled by staff and was frequently incontinent of bladder and continent of bowel. The resident was coded to have received antipsychotic medication without a gradual dose reduction being attempted and no documentation that a gradual dose reduction was clinically contraindicated.

Review of Resident #24's Care Plan revealed a focus listed as Behavior: the resident had a potential to be verbally and physically aggressive, wander and reject care. Interventions were listed to administer medications as ordered, give the resident as many choices a possible, allow time for the resident to express self and feelings, encourage the resident to participate in activities when restless or agitated, and the resident was to be seen by the in-house psychiatric provider.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 A review of Resident #24's Behavior documentation record for the month of July 2024 revealed no documentation of the resident having behaviors. Level of Harm - Minimal harm or potential for actual harm A review of Resident #24's Physician Orders for the month of July 2024 revealed the resident had orders to receive Seroquel, (an antipsychotic medication) 50 milligrams every morning and night and 25 milligrams in Residents Affected - Few the afternoon, and Haloperidol (an antipsychotic medication) 1 milligram every 12 hours as needed. The Haloperidol as needed order did not have a 14-day discontinuation date.

In an interview on 07/31/2024 at 2:45 PM with the Assistant Director of Nursing (ADON), the ADON confirmed that Resident #24's as needed Haloperidol did not have a discontinue date for the order and the order was indicated for indefinite use. The ADON stated the resident had not been seen by a psychiatric provider as stated as an intervention in the care plan and the resident and or their representative was not informed of the risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41938 potential for actual harm Licensure Reference Number 175 NAC 12-006.10(D) Residents Affected - Some 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.

Findings are:

Record review of the undated facility Insulin Administration for Qualified Medication Aide (QMA) (a Medication Aide) Competency Checklist revealed that the QMA must perform the procedure with 100% accuracy for competency. The steps for preparing an insulin pen and administering insulin revealed the staff is to check the Medication Administration Record (MAR) for the insulin order. Remove the (insulin) pen cap. Wipe the pen tip with an alcohol wipe. Remove the protective seal from a new needle and screw the needle

in place. Dial a dose of 2 units to prime the pen. Hold the pen with the needle pointing straight up and tap lightly so the bubbles will rise to the top. Press the injection button all the way in and check to see that the insulin comes out of the needle (If no insulin comes out, repeat the test. If insulin still does not come out, get

a new needle.) Check the order for the correct dose. Make sure the window shows 0 and then select the dose. Select the correct dose and dial until the number shows in the window. Take the medication and supplies to the resident.

Record review of the Admission Record dated 7/31/24 for Resident 40 revealed that Resident 40 admitted into the facility on [DATE REDACTED]. Resident 40 had a diagnosis of Diabetes.

the tip of the pen. (MA-I had not applied the needle and had not held the pen tip upward to prime the pen as required- a medication error). MA-I applied the needle and dialed the pen to a dose of 6 units. MA-I wiped

the stomach of Resident 40 with an alcohol prep pad. MA-I tried to inject the insulin into the stomach of Resident 40, but the pen/needle would not click. MA-I returned to the medication cart and removed the needle and discarded it into the sharps container. MA-I applied a new needle. MA-I dialed the pen to 6 units and returned to the resident room. (MA-I did not prime the new needle). MA-I wiped a different area on the resident's stomach and injected the insulin and held the needle in place for 20 seconds at 4:08 PM. MA-I returned to the medication cart and documented the administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Record review of the MAR (a legal record of the medications administered to a patient at a facility by a health care professional) dated 7/31/24 for Resident 40 revealed that Resident 40 had an order for sliding scale Level of Harm - Minimal harm or insulin. The MAR revealed that MA-I documented that 6 units of insulin were administered to Resident 40 for potential for actual harm the 7/30/24 4:30 PM sliding scale insulin order.

Residents Affected - Some Interview on 8/1/24 at 9:14 AM with the facility Director of Nursing (DON) confirmed that the expectation is that staff follow the facility procedure for insulin administration. The DON confirmed that the needle is to be applied to the insulin pen prior to priming the pen. The DON confirmed that once the needle is applied to the insulin pen the insulin pen is dialed to 2 units. The DON confirmed the insulin pen is then held with the tip of

the needle up when priming the pen to remove any air and ensure the correct insulin dose will be administered.

Record review of the Admission Record dated 8/1/24 for Resident 48 revealed that Resident 48 admitted into

the facility on [DATE REDACTED]. Resident 48 had a diagnosis of Diabetes.

Observation on 7/30/24 at 4:35 PM at a medication cart on the 200 hall revealed that Medication Aide-J (MA-J) reviewed the insulin order for Resident 48. MA-J revealed the order for Resident 48 to receive 2 units of Lispro insulin. MA-J removed the cap from the insulin pen. MA-J applied a needle to the insulin pen and dialed the pen to 2 units. MA-J held the tip of the pen downward and pushed the plunger to prime the needle. (MA-J did not hold the tip of the pen/needle upward to prime the pen/needle as required-a medication error). MA-J dialed the insulin pen to the ordered dose of 2 units and went to the resident's room. MA-J wiped an area on the resident's upper right arm with an alcohol prep pad. MA-J and injected the insulin. MA-J held the needle in place for several seconds. MA-J returned to the medication cart and documented the administration.

Interview on 8/1/24 at 2:12 PM with MA-J revealed that MA-J was trained on use of insulin pens in December or January of last year (2023). MA-J revealed the steps for administering insulin with the insulin pen begin with removing the cap from the insulin pen. MA-J then places a needle on the pen and dials the pen to 2 units to prime. MA-J revealed that the insulin pen is held with the tip of the needle held down towards the trash can and the plunger is pushed so you can see insulin drip. MA-J revealed that MA-J then dials the ordered dose of insulin to administer to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Observation on 7/31/24 at 11:32 AM on the facility 200 hall revealed that Medication Aide-I (MA-I) revealed a blood sugar of 161 for Resident 16 meant Resident 16 was to receive 2 units of insulin. MA-I removed the Level of Harm - Minimal harm or insulin pen from the medication cart and removed the cap from the Lispro insulin pen. MA-I applied a needle potential for actual harm to the insulin pen. MA-I dialed the insulin pen to 2 units. MA-I held the tip of the insulin pen downward and pushed the plunger to prime the pen. (MA-I did not hold the tip of the pen/needle upward to prime the Residents Affected - Some pen/needle as required-a medication error). MA-I dialed the pen to the dose of 2 units and went to the room of Resident 16. MA-I wiped an area on the resident's stomach with an alcohol prep pad. MA-I placed the needle against the resident's stomach and injected the insulin and held the needle in place for 20 seconds.

Record review of the MAR dated 8/1/24 for Resident 16 revealed that Resident 16 had an order for sliding scale insulin. The MAR revealed that MA-I documented that 2 units of insulin were administered to Resident 16 for the 7/31/24 11:30 AM sliding scale insulin order.

Record review of the facility policy titled Installation of Eye Drops dated January 2014 revealed that the steps for the procedure included: Gently pull the lower eyelid down. Instruct the resident to look up. Drop the medication into the mid lower eyelid.

Observation on 7/31/24 at 11:41 AM at the medication cart on the 200 hall revealed that Medication Aide-I (MA-I) performed med set up for Resident 40. MA-I reviewed the order for Resident 40 to receive Systane eye drop (a liquid medication used to treat dry eyes) one drop in each eye. MA-I entered the room of Resident 40. MA-I washed the hands and then applied gloves. Resident 40 sat in a wheelchair in the room. MA-I opened the bottle of Systane eye drops. MA-I squeezed the eye drop bottle and dropped 1 drop on the top of the right eyelid. (MA-I did not pull down on the lower eyelid to apply the drop into the lower eyelid as required) MA-I then pulled up on the top eyelid of the right eye and squeezed the eye drop bottle. A drop fell from the bottle onto the top of the closed bottom eyelid. The eye drop did not go into the eye (a medication error as the eye drop was not received in the eye). MA-I then moved their hands to the left eye of Resident 40. MA-I pulled up the top eyelid of the resident's left eye and applied a drop to the left eye. The drop landed

on the eyeball.

Record review of the MAR dated 7/31/24 for Resident 40 revealed that Resident 40 had an order for Systane eye drops to give 1 drop in each eye four times a day. The MAR revealed that MA-I documented that 1 drop was administered to each eye of Resident 40 for the 7/31/24 12:00 PM order.

Interview on 8/1/24 at 9:14 AM with the facility Director of Nursing (DON) confirmed that the expectation for administering eye drops is that staff pull down on the lower eyelid and place the eye drop in the lower eyelid pocket for proper administration. The DON confirmed that staff should not pull up on the upper eyelid. The DON confirmed that the eye drop was not administered if it did not go into the eye.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41938 potential for actual harm Licensure Reference Number 175 NAC 12-006.10D Residents Affected - Few 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.

Findings are:

Record review of the Admission Record dated 7/31/24 for Resident 40 revealed that Resident 40 admitted into the facility on [DATE REDACTED] and had a diagnosis of Diabetes.

Observation on 7/30/24 at 4:02 PM at the medication cart on the 200 hall revealed that MA-I obtained supplies and went to the room of Resident 40. MA-I wiped the pad of the resident's left little finger with the alcohol prep pad. MA-I used the lancet to prick the finger pad. MA-I squeezed the finger and a drop of blood appeared. MA-I applied the drop of blood to the glucometer test strip. MA-I revealed a blood sugar result of 277. MA-I returned to the medication cart. MA-I entered the blood sugar result and verified Resident 40 was to receive 6 units of Lispro insulin (a type of fast acting insulin). MA-I obtained the insulin pen and set the dial to 2 units. MA-I pushed the plunger as MA-I held the top of the pen downward and a drop of insulin appeared at the top of the pen. (MA-I had not applied the needle and held the pen upward to prime the pen as required). MA-I applied the needle and dialed the pen to a dose of 6 units. MA-I wiped the stomach of Resident 40 with an alcohol prep pad. MA-I tried to inject the insulin into the stomach of Resident 40, but the pen/needle would not click. MA-I returned to the medication cart and removed the needle and discarded it into the sharps container. MA-I applied a new needle. MA-I dialed the pen to 6 units and returned to the resident room. (MA-I did not prime the new needle). MA-I wiped a different area on the resident's stomach and injected the insulin and held the needle in place for 20 seconds at 4:08 PM. MA-I returned to the medication cart and documented the administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Record review of the MAR (a legal record of the medications administered to a patient at a facility by a health care professional) dated 7/31/24 for Resident 40 revealed that Resident 40 had an order for sliding scale Level of Harm - Minimal harm or insulin. The MAR revealed that MA-I documented that 6 units of insulin were administered to Resident 40 for potential for actual harm the 7/30/24 4:30 PM sliding scale insulin order.

Residents Affected - Few Interview on 8/1/24 at 9:14 AM with the facility Director of Nursing (DON) confirmed that the expectation is that staff follow the facility procedure for insulin administration. The DON confirmed that the needle is to be applied to the insulin pen prior to priming the pen. The DON confirmed that once the needle is applied to the insulin pen the insulin pen is dialed to 2 units. The DON confirmed the insulin pen is then held with the tip of

the needle up when priming the pen to remove any air and ensure the correct insulin dose will be administered.

Record review of the Admission Record dated 8/1/24 for Resident 48 revealed that Resident 48 admitted into

the facility on [DATE REDACTED]. Resident 48 had a diagnosis of Diabetes.

Observation on 7/30/24 at 4:35 PM at a medication cart on the 200 hall revealed that Medication Aide-J (MA-J) reviewed the insulin order for Resident 48. MA-J revealed the order for Resident 48 to receive 2 units of Lispro insulin. MA-J removed the cap from the insulin pen. MA-J applied a needle to the insulin pen and dialed the pen to 2 units. MA-J held the tip of the pen downward and pushed the plunger to prime the needle. (MA-J did not hold the tip of the pen/needle upward to prime the pen/needle as required). MA-J dialed the insulin pen to the ordered dose of 2 units and went to the resident's room. MA-J wiped an area on the resident's upper right arm with an alcohol prep pad. MA-J injected the insulin. MA-J held the needle in place for several seconds. MA-J returned to the medication cart and documented the administration.

Record review of the MAR dated 7/31/24 for Resident 48 revealed that Resident 48 had an order for sliding scale insulin. The MAR revealed that MA-J documented that 2 units of insulin were administered to Resident 48 for the 7/30/24 5:30 PM sliding scale insulin order.

Record review of the Admission Record dated 7/29/24 for Resident 16 revealed that Resident 16 admitted into the facility on [DATE REDACTED]. Resident 16 had a diagnosis of Diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Observation on 7/31/24 at 11:32 AM on the facility 200 hall revealed that Medication Aide-I (MA-I) revealed a blood sugar of 161 for Resident 16 meant Resident 16 was to receive 2 units of insulin. MA-I removed the Level of Harm - Minimal harm or insulin pen from the medication cart and removed the cap from the Lispro insulin pen. MA-I applied a needle potential for actual harm to the insulin pen. MA-I dialed the insulin pen to 2 units. MA-I held the tip of the insulin pen downward and pushed the plunger to prime the pen. (MA-I did not hold the tip of the pen/needle upward to prime the Residents Affected - Few pen/needle as required). MA-I dialed the pen to the dose of 2 units and went to the room of Resident 16. MA-I wiped an area on the resident's stomach with an alcohol prep pad. MA-I placed the needle against the resident's stomach and injected the insulin and held the needle in place for 20 seconds.

Record review of the MAR dated 8/1/24 for Resident 16 revealed that Resident had an order for sliding scale insulin. The MAR revealed that MA-I documented that 2 units of insulin were administered to Resident 16 for

the 7/31/24 11:30 AM sliding scale insulin order.

Interview on 8/1/24 at 9:14 AM with the facility Director of Nursing (DON) confirmed that the expectation is that staff follow the facility procedure for insulin administration. The DON confirmed that the needle is to be applied to the insulin pen prior to priming the pen. The DON confirmed that once the needle is applied to the insulin pen the insulin pen is dialed to 2 units. The DON confirmed the insulin pen is then held with the tip of

the needle up when priming the pen to remove any air and ensure the correct insulin dose will be administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50253

Residents Affected - Many License 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.

Findings are:

Observation on 08/01/24 at 10:00 AM of a Placard on the side of the [NAME] dishwasher indicated the minimum temperatures needed for the wash cycle was to 160 degrees Fahrenheit and the minimum for the rinse cycle was to be 180 degrees Fahrenheit.

Observation on 8/01/2024 at 10:15 AM of the kitchen dishwasher revealed the wash cycle temperature was

a 145 Degrees Fahrenheit (DF) and the rinse cycle was 163 DF.

An interview was conducted on 8/01/2024 at 10:10 AM with Dietary Aide (DA) Q. During the interview DA-Q reported not knowing if the dishwasher was low or high temp and didn't know what temps needed to be reached to facilitate cleaning of the dishes.

Interview on 08/01/24 at 10:13 AM with the DD. DD did not know what temperatures needed to be reached

on the wash and the rinse cycles just knew they had to be hot. Nor did the DD know what the blinking light was on the dishwashing monitor.

Interview on 8/1/24 at 10:15 AM with Dietary Aide - V (DA-V) who stated the blinking light meant that the machine was nearly out of dishwashing detergent. Confirmed the washer will stop completely when it runs out and needs refilled.

Interview on 08/01/24 at 10:31 AM with Maintenance Personnel (MAINT) Stated the dishwasher was a high temp dishwasher and the temperature dishwasher.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

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.

Findings are:

Record review of the undated and untitled list of facility employees revealed that Medication Aide-E (MA-E) had a hire date of 5/9/24.

Record review of the Employee Health Screening Post Conditional Offer dated 5/9/24 for MA-E revealed that

it was signed by MA-E on 5/9/24. The line for the RN (Registered Nurse) Signature was blank.

Interview on 8/1/24 at 8:56 AM with the facility Human Resources (HR) revealed that the facility Employee Health Screening form is in the orientation packet. HR revealed that the staff member fills out the health screening form and returns it to HR. HR confirmed that the health screening form is placed into the employee file and is not reviewed. HR confirmed that the Employee Health Screening form is not reviewed by nursing or anyone else to assess for potential communicable diseases. HR confirmed that the information on the form should be reviewed and accepted with a signature of an RN.

Record review of the undated and untitled list of facility employees revealed that Maintenance Worker-H (MW-H) had a hire date of 5/9/24.

Record review of the Employee Health Screening Post Conditional Offer dated 5/9/24 for MW-H revealed that it was signed by MW-H on 5/9/24. The line for the RN (Registered Nurse) Signature was blank.

Record review of the undated and untitled list of facility employees revealed that Nurse Aide-F (NA-F) had a hire date of 5/30/24.

Record review of the Employee Health Screening Post Conditional Offer dated 5/30/24 for NA-F revealed that it was signed by NA-F on 5/30/24. The line for the RN (Registered Nurse) Signature was blank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 D.

Level of Harm - Minimal harm or Record review of the undated and untitled list of facility employees revealed that Transportation Driver (TD) potential for actual harm had a hire date of 6/13/24.

Residents Affected - Many Record review of the Employee Health Screening Post Conditional Offer dated 6/12/24 for TD revealed that it was signed by TD on 6/12/24. The line for the RN (Registered Nurse) Signature was blank.

Record review of the undated and untitled list of facility employees revealed that Medication Aide-G (MA-G) had a hire date of 7/11/24.

Record review of the Employee Health Screening Post Conditional Offer dated 7/11/24 for MA-G revealed that it was signed by MA-G on 7/11/24. The line for the RN (Registered Nurse) Signature was blank.

50105

On 07/31/2024 from 7:44 AM until 8:45 AM revealed Medication Assistant 9 MA)-N and MA-Y both entered room [ROOM NUMBER] to assist a resident out of the bed with a Hoyer lift. MA-N and MA-Y were observed leaving room [ROOM NUMBER] pushing the Hoyer lift into room [ROOM NUMBER] without sanitizing the hoyer lift before or after its use. The Hoyer lift was brought out of room [ROOM NUMBER] and parked for storage. MA-N and MA-Y did not sanitize the hoyer lift after using it in room [ROOM NUMBER]. MA-A N without sanitizing the same hoyer lift brought the hoyer lift into room [ROOM NUMBER]. Further review revealed MA-N completed using the hoyer left pushed out of room [ROOM NUMBER] and did not sanitize

the hoyer lift.

On 7/31-2024 at 8:45 AM an interview was conducted with MA-N. During the interview MA-N reported not being aware of who is responsible to sanitize the hoyer lift after use.

An interview on 07/31/2024 at 10:32 AM with the Infection Control Coordinator (ICC) revealed that staff use a different sling for each resident who uses the Hoyer lift and sit to stand equipment. The ICC further revealed that cleaning multi-use equipment should be done in-between use by the nursing department.

Record review of the facility Emergency Preparedness Plan revealed there was no information on the facility water management plan that included monitoring for and prevention of Legionella and any other water borne pathogen.

An interview with the Maintenance Director revealed there is no water management plan available for the facility. The Maintenance Director confirmed there were no measures being taken to prevent the growth of Legionella. Further interview with the Maintenance Director revealed there is no monitoring processes in place when control limits are not met.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Record review revealed documentation and communication on all activities for a water management plan was not happening. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 285095 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 285095 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Rehabilitation and Care Center 111 West 36th Street Scottsbluff, NE 69361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49382 potential for actual harm Licensure Reference Number 175 NAC 12-009.04 Residents Affected - Few 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.

Findings are:

Review of a facility policy labeled Maintenance Service dated 12/2009 revealed maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

In an observation on 07/29/2024 at 3:04 PM flying insects were observed to be gathering in the corner of a window located in the courtyard across the hall from room [ROOM NUMBER] and 122. A resident was observed to be sitting in their wheelchair in the gazebo in the courtyard area. A wasp nest was present to the upper right-hand corner of the window frame approximately the size of a soft ball with multiple wasps visibly crawling on the nest and flying to and from the nest.

In an interview on 07/29/2024 at 3:20 PM with Registered Nurse A (RN-A), RN-A confirmed that residents go out to the courtyard across from room [ROOM NUMBER] and 122 to sit and enjoy the flowers and the weather. RN-A denies having problems with flying insects in the facility that they are aware of.

In an interview on 08/01/2024 at 10:05 AM with the Maintenance Director (MD) the MD confirmed there was

an active wasp's nest present to the upper right-hand corner of the window of the courtyard. The MD stated that the nest had been observed approximately a week ago and had not had the time to exterminate the wasps. The MD stated the exterminator comes monthly for pest and insect control and confirmed that the active wasp nest was a potential hazard to the residents wishing to go out into the court yard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 285095

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Monument Rehabilitation And Care Center

Inspection Findings

F-Tag F678

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