The Vardell Report.Monument Healthcare and Nursing Center

Across 9 inspections from July 2023 to August 2026, state surveyors documented 52 findings at Monument Healthcare and Nursing Center; 45 have a recorded correction and 7 await one; CMS lists 2 enforcement actions in the window.

Inspections

9

2023–2026, complaint and standard

Findings

52

Deficiencies cited by state inspectors

Corrected

45

Of 52 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 312026

   Complaint investigation

   7 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F923Have enough outside ventilation via a window or mechanical ventilation, or both.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 92026

   Complaint investigation

   1 finding

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Jun 15, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Aug 162025

   Standard health inspection

   10 findings

   The same visit included a complaint investigation.

   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Sep 10, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Sep 10, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level DNo actual harm, potential for moreCorrected Sep 10, 2025
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Sep 10, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jul 92025

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 25, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Apr 32025

   Complaint investigation

   6 findings

   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level GActual harmCorrected Apr 28, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 28, 2025
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Apr 28, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Dec 162024

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 10, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 10, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Aug 12024

   Standard health inspection

   15 findings

   The same visit included a complaint investigation.

   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Aug 29, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 29, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Aug 29, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Aug 29, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Aug 29, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Aug 29, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Aug 29, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Aug 29, 2024
   • F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Level CPotential for minimal harmCorrected Aug 29, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Aug 29, 2024

   Enforcement Action

   Civil money penalty, $11,438 imposed August 1, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 1, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $16,744 imposed April 3, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 1, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Nov 152023

   Complaint investigation

   1 finding

   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 27, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Jul 132023

   Standard health inspection

   9 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 25, 2023
   • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
   • F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Level CPotential for minimal harmCorrected Aug 25, 2023
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level CPotential for minimal harmCorrected Aug 25, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in July 2023, August 2024 and August 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F812 across all 9 inspections, oldest to newest
2. 2

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in August 2024, December 2024 and August 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F880 across all 9 inspections, oldest to newest
3. 3

   Citation F606, Cited in Two Inspections

   Inspectors cited F606 in July 2023 and August 2024. The agency describes it this way: Not hire anyone with a finding of abuse, neglect, exploitation, or theft. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F606 across all 9 inspections, oldest to newest
4. 4

   Accurate Assessments, Cited in Two Inspections

   Inspectors cited F641 in July 2023 and August 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F641 across all 9 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in August 2024 and December 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F684 across all 9 inspections, oldest to newest
6. 6

   Psychotropic Medications, Cited in Two Inspections

   Inspectors cited F758 in August 2024 and April 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242525252626F758 across all 9 inspections, oldest to newest
7. 7

   Dignity and Resident Rights, No Recorded Correction

   F550 was cited in June 2026 and August 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. The most serious was level F (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   232324242525252626F550 across all 9 inspections, oldest to newest
8. 8

   A Clean, Homelike Setting, No Recorded Correction

   F584 was cited in August 2024 and August 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. The most serious was level F (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   232324242525252626F584 across all 9 inspections, oldest to newest
9. 9

   Care Plans, No Recorded Correction

   F656 was cited in August 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   232324242525252626F656 across all 9 inspections, oldest to newest
10. 10

    Care Plan Timing and Review, No Recorded Correction

    F657 was cited in April 2025 and August 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242525252626F657 across all 9 inspections, oldest to newest
11. 11

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in August 2024, April 2025 and August 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242525252626F689 across all 9 inspections, oldest to newest
12. 12

    Nursing Staff Levels, No Recorded Correction

    F725 was cited in August 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. The most serious was level F (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242525252626F725 across all 9 inspections, oldest to newest
13. 13

    Citation F923, No Recorded Correction

    F923 was cited in August 2026. The agency describes it this way: Have enough outside ventilation via a window or mechanical ventilation, or both. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    232324242525252626F923 across all 9 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

2. 02

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

3. 03

   What changed after F606 was cited, and how do you check it now?

   Citation F606: cited in two inspections, most seriously at level C.

4. 04

   Who completes resident assessments, and how are they checked for accuracy?

   Accurate Assessments: cited in two inspections, most seriously at level D.

5. 05

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level E.

6. 06

   How many residents take psychotropic medications, and how often are doses reviewed for reduction?

   Psychotropic Medications: cited in two inspections, most seriously at level D.

7. 07

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in two inspections, most seriously at level F. The August 31, 2026 citation has no recorded correction date.

8. 08

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in two inspections, most seriously at level F. The August 31, 2026 citation has no recorded correction date.

9. 09

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in one inspections, most seriously at level E. The August 31, 2026 citation has no recorded correction date.

10. 10

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level E. The August 31, 2026 citation has no recorded correction date.

11. 11

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in three inspections, most seriously at level D. The August 31, 2026 citation has no recorded correction date.

12. 12

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Nursing Staff Levels: cited in one inspections, most seriously at level F. The August 31, 2026 citation has no recorded correction date.

13. 13

    What changed after F923 was cited, and how do you check it now?

    Citation F923: cited in one inspections, most seriously at level E. The August 31, 2026 citation has no recorded correction date.

14. 14

    What led to the 2025 fine, and has it been paid?

    A $16,744 civil money penalty was imposed April 3, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Nebraska state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Jul 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Nov 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Aug 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Dec 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Apr 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Jul 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Aug 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Jun 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Nebraska state survey agency

  Inspection Aug 31, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 285095

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.