Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Standing Stone Care And Rehab during CMS and state inspections, most recent first.
A facility failed to update the PASRR for a resident with PTSD and a new diagnosis of Depression. The resident was admitted with Dementia, PTSD, Muscle Weakness, and Kidney Failure, and had impaired cognitive skills. The PASRR Level 1 screen did not reflect these mental health conditions, and no referral was made to the state agency after the new diagnosis.
A facility failed to develop a person-centered care plan for a resident with PTSD, despite having a policy requiring such plans to address mental and psychosocial needs. The resident, with moderate cognitive impairment and an active PTSD diagnosis, did not have a care plan for PTSD, as confirmed by MDS Coordinators.
A resident receiving enteral nutrition had their tube feeding formula unlabeled, contrary to facility policy requiring labeling with formula type, date, time, and nurse's initials. The LPN and DON confirmed the oversight, which was identified as a deficiency during a survey.
The facility failed to prevent multiple incidents of resident-to-resident abuse, involving residents with cognitive impairments and behavioral issues. Despite care plans and supervision, altercations occurred, highlighting inadequate measures to ensure resident safety.
A resident with moderate cognitive impairment reported sexual advances by an EVS to a housekeeper, who failed to report the allegations immediately. The resident later expressed fear to an RN, who also delayed reporting. The full nature of the allegations was only revealed after the resident spoke with the medical director, leading to a delay in reporting to authorities, violating the facility's abuse policy.
Failure to Update PASRR for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) for a resident who had an active mental health condition upon admission. The facility's policy requires that residents be evaluated for serious mental illness, and if a serious mental disorder arises later, a referral should be made promptly. However, the PASRR Level 1 screen outcome for the resident, dated 10/28/2024, did not include the diagnosis of PTSD, which was present upon admission. Additionally, the facility did not refer the resident to the state-designated PASRR agency after identifying PTSD and a new diagnosis of Depression. The resident was admitted with diagnoses including Dementia, PTSD, Muscle Weakness, and Kidney Failure. A 5-day admission Minimum Data Set (MDS) assessment revealed the resident had short-term and long-term memory impairment and severely impaired cognitive skills for daily decision-making. Despite these findings, the facility did not update the PASRR to reflect the resident's mental health conditions. The Infection Preventionist/Staff Development Coordinator confirmed that the PASRR Level 1 outcome was not updated to include PTSD and that no referral was made after the new diagnosis of Depression was added.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with an active diagnosis of Post Traumatic-Stress Disorder (PTSD). The facility's policy requires the development and implementation of such care plans to meet residents' mental and psychosocial needs as identified in comprehensive assessments. Despite this policy, a review of the medical record for the resident, who was admitted with diagnoses including Major Depressive Disorder, Anxiety Disorder, and PTSD, revealed the absence of a person-centered care plan specifically addressing PTSD. This deficiency was confirmed during an interview with two MDS Coordinators, who acknowledged the lack of a care plan for the resident's PTSD, despite the resident's moderate cognitive impairment and active diagnosis of PTSD.
Failure to Label Tube Feeding Formula Appropriately
Penalty
Summary
The facility failed to appropriately label a tube feeding formula for a resident who was receiving enteral nutrition. The facility's policy requires that tube feeding bags be labeled with the type of formula, strength, amount, date, time, and the nurse's initials. However, during an observation, it was noted that the tube feeding formula for a resident was not labeled or dated as per the policy. The resident, who was cognitively intact, had been admitted with diagnoses including Protein-Calorie Malnutrition, Dysphagia, and Gastrostomy, and was receiving enteral feeding as per a physician's order. The deficiency was confirmed during interviews with the LPN and the Director of Nursing (DON). The LPN acknowledged that the tube feeding formula should have been labeled and dated during the previous shift, but it was not. The DON also confirmed that the labeling was not done appropriately, which was against the facility's guidelines. This oversight in labeling the tube feeding formula was identified as a deficiency during the survey.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. In one instance, a resident with severe cognitive impairment pushed another resident in a wheelchair, resulting in no injuries but highlighting a lack of effective supervision and intervention. The involved residents had histories of dementia and other cognitive impairments, which were documented in their care plans, yet the facility's measures to prevent such incidents were inadequate. Another incident involved a resident striking another in the back, causing a fall. The aggressor, who had a history of restlessness and agitation, was under supervision but still managed to engage in physical aggression. The victim, who also had cognitive impairments, was not injured, but the event underscores the facility's failure to maintain a safe environment for residents with known behavioral issues. Further incidents included a resident striking another, resulting in redness and potential injury, and another case where a resident was observed hitting a peer. These events were witnessed by staff, who intervened, but the repeated nature of these altercations indicates systemic issues in managing residents with behavioral disturbances. The facility's policies and interventions were insufficient to prevent these occurrences, despite the residents' documented needs for supervision and behavioral management.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility's direct care staff failed to immediately report allegations of staff-on-resident abuse, resulting in a delay in reporting the abuse to the State Designated Authority. The incident involved a resident who reported to a housekeeper that the Environmental Services Supervisor (EVS) had made sexually explicit statements and propositions for sexual intercourse. The housekeeper did not escalate or report these allegations, leading to a delay in the facility leadership being made aware of the situation. The resident, who had moderate cognitive impairment, later expressed fear of the EVS to a registered nurse, but the nurse also failed to report the concerns immediately to the Director of Nursing or the abuse coordinator. It was not until the resident spoke with the facility's medical director that the full nature of the allegations was revealed, prompting the Director of Nursing to report the incident to the appropriate authorities. This delay in reporting exceeded the required two-hour timeframe for reporting abuse allegations to the state. The facility's policy required immediate reporting of any abuse allegations, but the staff involved did not adhere to this policy. The housekeeper assumed the resident would repeat the allegations to the nurse, and the nurse did not take immediate action upon hearing the resident's concerns. This series of inactions led to a significant delay in addressing the resident's allegations and reporting them to the state, which was a violation of the facility's abuse policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monterey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Putnam County | 10.4 mi | ★★★★★ | 0 | 0 |
| Grandview Post Acute | 11.3 mi | ★★★★★ | 2 | 0 |
| Wharton Nursing Home | 12.6 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Cookeville | 13.4 mi | ★★★★★ | 0 | 0 |
| Overton County Health And Rehab Center | 16.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.