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Inspection visit

Health inspection

MONROEVILLE POST ACUTECMS #39600319 citations on this visit
19 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 19 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of 16 sampled residents (Resident R47 and R36). Findings: Review of facility policy Dignity reviewed 11/1/24, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record revealed Resident R47 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/26/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and muscle wasting. Review of Section C: Cognitive Patterns, indicated severe cognitive impairment. Review of Section G:, revealed physical impairments of both the upper and lower extremities on both sides of the body, and that Resident R47 was dependent on staff for both upper and lower body dressing. During an observation on 12/17/24, at 9:37 a.m. Resident R47 was in the hallway, dressed in a sweater and athletic shoes. Resident R47 did not have any clothing on her lower body, and the brief was visible. During an interview on 12/17/24, at 9:40 a.m. Unit Manager Employee E3 confirmed that Resident R47 Page 1 of 26 396003 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0550 had no clothing on the lower body. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/24, at Nurse Aide Employee E4 stated, when asked if Resident R47 was able to put her clothing or shoes on, or take them off, stated, No, not at all. Residents Affected - Some Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Myelopathy (an injury to the spinal cord symptoms can include pain, difficulty walking loss of bowel and bladder control) and cervical vertebra fractures (commonly called a broken neck). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 14. Review of Section GG 0130 Functional Abilities and Goals: revealed Resident R36 was dependent for bed and chair mobility. During an interview on 12/18/24, at 10:56 a.m. Resident R36 stated one night in 10/24 (unable to recall exact date) his call light repeatedly activated on its own. A staff member entered his room and said, you touch that thing one more time and you're getting in the hoyer and going to the television room for the rest of the night. At approximately 1:30 a.m. staff got Resident R36 out of bed and placed him in the television room until approximately 7:30 a.m. Resident R36 asked facility staff for a supervisor and he contacted the police from his cell phone. He reported the police informed him he needs to work this out with the facility, and he did not get to see the facility supervisor. Resident R36 stated he was informed the day after the incident, there was a malfunction with his call light that was repaired. During an interview on 12/18/24, with the Nursing Home Administrator (NHA) a request was made for work orders and repairs to the call system for the month of 10/24. The NHA confirmed the TELS (electronic work order system) was not functioning during this time and there are no records available for review. During review of facility reported incidents and the facility complaint and grievance files for the months of September, October, November and December, there is no record of the event. During an interview on 12/19/24, at approximately 2:21 p.m., the NHA and Director of Nursing (DON) confirmed they were unaware of this event reported by Resident R36. The NHA and DON confirmed that an investigation, report, and follow up will be conducted. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of sixteen residents. 28 Pa. Code 201.29(j) Resident rights. 396003 Page 2 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interview, it was determined that the facility failed to post contact information for the Medicaid Fraud Unit and Adult Protective Services as required, on two of two (first and second floor) nursing units. Findings include: Observations conducted on December 17, 2024, at 9:30 a.m., on the first and second floor nursing units, revealed the facility did not have the Medicaid Fraud Unit contact information posted or accessible to residents. Observations conducted on December 17, 2024, at 9:30 a.m., on the first and second floor nursing units, revealed the facility did not have the Adult Protective Services contact information posted or accessible to residents. During interview, on December 17, 2024, at 2:40 p.m., the Nursing Home Administrator confirmed that the Adult Protective Services and Medicaid Fraud Unit contact information was not posted in areas available to residents and visitors. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management. 396003 Page 3 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, resident group interview and staff interview, it was determined that the facility failed to post notice of the availability of survey results in a prominent location on two of two nursing units (first and second floors). Residents Affected - Many Findings include: During an observation on 12/17/24, at 9:40 a.m. no signage was identified indicating survey results are available. During a resident group interview on 12/17/24, at 10:30 a.m. 10 out of 10 residents agreed that they were unaware of the location of the survey results (Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). During an interview on 12/17/24, at 2:40 p.m. the Nursing Home Administrator, confirmed the facility failed to post notice of the location of survey results in the facility. 28 Pa. Code 201.13(g) Issuance of license. 396003 Page 4 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0579 Provide information about how to apply for and use Medicare and Medicaid benefits. Level of Harm - Potential for minimal harm Based on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (first and second floor). Residents Affected - Many Findings include: Observations conducted on 12/17/24, at 9:30 a.m., on the first and second floor nursing units, revealed the facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid . During interview, on 12/17/24, at 2:40 p.m., the Nursing Home Administrator confirmed the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (first and second floor). 28 Pa. Code: §201.29(i) Resident rights. 396003 Page 5 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor 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. Based on observations and resident and staff interviews it was determined that the facility failed to provide a clean and homelike environment on one of six nursing units (One East nursing unit) and for two of two residents (Residents R35 and R4). Findings include: During an observation on 12/20/24, at 11:00 a.m., of the One East nursing unit (Room of R4 and R35) the ceiling tile above the toilet revealed a large brown colored stain. During an interview on 12/20/24, at 11:05 a.m., Resident R35 stated The ceiling leaks down the wall and onto the floor. It's been going on for a long time. During an interview on 12/20/24 at 11:05 a.m., Resident R4 stated They changed the tile 3 times and it keeps happening. During an interview on 12/20/24 at 11:30 a.m., The Nursing Home Administrator confirmed the above findings and that the facility failed to provide a clean, comfortable homelike environment on One East nursing. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights. 396003 Page 6 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident record, investigation documents, and staff interview, it was determined that the facility failed to report an allegation of neglect for one of four sampled residents (Resident R166). Findings include: A review of the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated that the facility will thoroughly investigate and report all allegations of abuse/neglect and will report to the Administrator and other officials as required. A review of Resident R166's admission record indicated the resident was admitted on [DATE], with diagnoses that included fracture of the cervical (neck) vertebrae, high blood pressure, and pain. Resident R166 discharged to home on [DATE]. A review of Resident R166's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 11/12/24, indicated that the diagnoses were current upon review and the resident was alert, oriented, and cognitively intact. A review of a nurse progress note dated 11/21/22, indicated Resident R166 had a high level of pain while a resident at the facility. A review of a facility grievance form dated 11/12/24, indicated Resident R166 stated the nursing staff was giving her a hard time about giving the resident pain medication. The night nurse refused to give the pain medication, stating I have 30 other residents to take care of. This concern was signed as received by the Director of Nursing (DON). A review of reports submitted to the local state field office did not include Resident R166's allegation of neglect. During an interview on 12/17/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to report Resident R166's allegation of neglect as required. 28 Pa Code: 201.14 (a) Responsibility of management. 28 Pa Code: 201.18 (e)(1) Management. 396003 Page 7 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated and the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for one of four residents reviewed. (Resident R166). Residents Affected - Few A review of the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated that the facility will thoroughly investigate all allegations of abuse/neglect and will report to the Administrator and other officials as required. A review of Resident R166's admission record indicated the resident was admitted on [DATE], with diagnoses that included fracture of the cervical (neck) vertebrae, high blood pressure, and pain. Resident R166 discharged to home on [DATE]. A review of Resident R166 Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 11/12/24, indicated that the diagnoses were current upon review and the resident was alert, oriented, and cognitively intact. A review of a nurse progress note dated 11/21/22, indicated Resident R166 had a high level of pain while a resident at the facility. A review of a facility grievance form dated 11/12/24, indicated Resident R166 stated the nursing staff was giving her a hard time about giving the resident pain medication. The night nurse refused to give the pain medication, stating I have 30 other residents to take care of. The grievance form indicated the facility would investigate the staff roster and description of the alleged perpetrator. This concern was signed as received by the Director of Nursing (DON). There was no documented evidence that the facility investigated the alleged incident of neglect for Resident R166. During an interview on 12/17/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to investigate an alleged incident of neglect for Resident R166. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.14 (c) (e) Responsibility of licensee. 28 Pa. Code: 201.18 (e) (1) Management. 28 Pa. Code: 201.20 (b) Staff development. 396003 Page 8 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident R106). Residents Affected - Few Findings include: Review of facility policy, titled Oxygen Administration, with a review date of 3/15/24, purpose is to provide guidelines for safe oxygen administration. This includes verification of a physician order for oxygen or facility protocol, portable oxygen, regulator checking equipment and periodic assessment. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R106's clinical record indicates admission to the facility on [DATE]. Review of Resident R106's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/24, indicated diagnoses of pressure ulcer (PU) of sacral region, pressure ulcer of left hip (open wound with tissue damage), paraplegia (paralysis of the lower half of the body) and severe protein calorie malnutrition (not enough protein and calories are consumed and/or metabolized). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. During an interview with Resident on 12/16/24 at 11:00 a.m., resident was actively using oxygen. With an oxygen concentrator (uses a process to create a purer oxygen from ambient air). in his room and two e-cylinder (portable oxygen tanks) at his bed side. During a second interview of Resident R106 on 12/18/24, at 10:00 a.m., Resident R106 was not wearing oxygen. He reported the two e-cylinders were empty and the concentrator only works for a short time before it alarms. Resident R106 reported that he intermittent has difficulty breathing and his concerned with the condition of the existing oxygen equipment. During an interview on 12/18/24, at approximately 10:15 a.m., Employee E1, confirmed the portable oxygen e-cylinders in Resident R106 room were empty and the oxygen concentrator needed replaced. Employee E1, removed the empty oxygen e-cylinders and had a replacement concentrator placed in Resident R106's room. During an interview on 12/19/24, at approximately 2:00 p.m., the Director of Nursing (DON) 396003 Page 9 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0695 confirmed the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident R106). Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.10(c)(d) Resident care policies. Residents Affected - Few 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 396003 Page 10 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 17 residents (Residents R10, R16, R59, R105, R27, R36, R318, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509. Findings include: Review of the facility policy Call System dated 11/1/24, indicated calls for assistance are answered as soon as possible. During an observation on 12/16/24, at 2:40 p.m., the call light for Resident R59 was noted to be alarming. During an interview on 12/16/24, at 2:46 p.m. Resident R59 was asked why she needed help, and she responded that she was thirsty, and hadn't had a drink. During an observation on 12/16/24, at 2:51 p.m. Registered Nurse (RN) Employee was observed walking by Resident R59's room door and looking inside. When it appeared that she noted the State Agency (SA) in the room, stopped abruptly, looked up at the call light, and backed up to enter the room to assist the resident. During a resident group interview on 12/17/24, at 10:30 a.m.,, ten of ten residents in attendance stated it often takes one hour or more for call lights to be answered (Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). During an interview on 12/17/24, at 11:54 a.m., Resident R105, when asked if she felt the facility maintained sufficient staff, stated, No and further stated that call lights take forever. During an interview on 12/17/24, at 12:00 p.m., Resident R27, when asked about call light response, stated it could be very long. During an interview on 12/17/24, at 2:34 p.m., Resident R318, when asked if he felt the facility maintained sufficient staff, stated, They are low on staffing, have a skeleton crew. During an interview on 12/17/24, at 2:38 p.m. Resident R319, when asked if she felt the facility maintained sufficient staff, stated, No. Resident R319 proceeded to describe long waits for call light responses, long waits for prescribed medications, and the need to go to the nurses' station for assistance as staff who stated they would assist her when answering the call light never returned to do so. During an interview on 12/18/24, at 10:30 a.m. Resident R10, when asked if she felt call lights are answered timely. Resident R10 laughed and asked, are you serious, it takes forever to get help. During an interview on 12/18/24, at 10:40 a.m. Resident R16, when asked to detail call light response time, she asked, is this a joke. You must plan ahead for what you need, you can find yourself 396003 Page 11 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0725 waiting up to an hour or more for help. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/18/24, at 10:56 a.m. Resident R36, when asked his thoughts on call light response. I waited 5 hours once to be cleaned after soiling myself. You're lucky if it takes less than an hour to get help. Residents Affected - Some During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 17 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services. 396003 Page 12 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication rooms (First Floor medication room). Findings include: Review of facility policy Medication Labeling and Storage dated 11/1/24, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the First Floor medication room on 12/16/24, at 2:05 p.m. the following was observed: -(1) vacutainer with an expiration date of 5/31/23. -(2) vacutainers with an expiration date of 11/30/23. -(34) vacutainers with an expiration date of 2/29/24. -(6) vacutainers with an expiration date of 3/31/24. -(10) vacutainers with an expiration date of 4/30/24. -(6) vacutainers with an expiration date of 8/31/24. -(5) vacutainers with an expiration date of 9/30/24. -(1) I.V. start kit with an expiration date of 2/29/24. -(6) Bacterial collection culture bottles with an expiration date of 11/6/24. -(6) Bacterial collection culture bottles with an expiration date of 11/13/24. -(4) Glucose monitoring control solutions with an expiration date of 9/22/24. -(1) Package of wound vacuum dressing with an expiration date of 2/29/24. During an interview on 12/16/24, at 2:36 p.m. Unit Manager Employee E3 confirmed the above observations. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 396003 Page 13 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0761 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Residents Affected - Few 396003 Page 14 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of facility policy and interview with residents and staff, it was determined that the facility failed to routinely offer or make available evening snacks as desired by nine of ten oriented residents (Residents R500, R501, R502, R503, R504, R505, R507, R508, and R509). Findings include: A review of facility policy Snacks (Between Meal and Bedtime), Serving dated 3/15/24. Indicates the purpose is to provide the resident with adequate nutrition. Facility staff report any problems or complaints made by the resident related to the snack. Report other information in accordance with the facility policy and professional standards of practice. Review of facility Snack Audits conducted during the months of August and September 2024 revealed only the volume and itemized list of snacks that were delivered to the nursing units. During a resident group interview on 12/17/24, at 10:30 a.m., nine of ten residents in attendance stated that they are not consistently offered a nourishing evening snack and there are not enough snacks for those who request them (Residents R500, R501, R502, R503, R504, R505, R507, R508, and R509). The residents in attendance expressed frustration about not having snacks and the alternative is purchasing snacks from the vending machine. The residents reported they no longer share this at the Resident Council Meeting as they fell it's a waste of time as there has been no improvement with snack availability. During an interview on 12/19/24, at approximately 2:15 p.m., the Nursing Home Administrator and Director of Nursing were unable to explain why residents are reporting the facility does not have enough evening snacks. The Director of Nursing confirmed it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 396003 Page 15 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and staff interview, it was determined that the facility failed to restrain hair and failed to perform handing washing to prevent the potential for cross contamination in the Kitchen. Findings include: Review of facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices reviewed 11/1/24, indicated food and nutritional services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands after handling soiled equipment or utensils. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of facility policy Policies and Procedures - Infection Prevention and Control reviewed 11/1/24, indicated the facility adopted infection prevention and control policies and procedures intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. During an observation in the Kitchen on 12/18/24, between 11:30 a.m. and 12:30 p.m., the following was observed: -At 11:33 a.m. Kitchen Aide Employee E5 was observed gathering food items for the dinner meal prep with a hair net that did not cover her two braided buns on the back of her head. -At 11:34 a.m. Kitchen Aide Employee E6 was observed working tray line assembly without a beard guard on. -At 12:15 p.m. [NAME] Employee E16 was observed placing soiled dishes in the dishwasher, and without washing her hands putting the clean dishes away. During an interview on 12/18/24, at 11:35 a.m., Kitchen Aide Employee E5 confirmed she did not have the hair net fully covering her hair. During an interview on 12/18/24, at 12:15 p.m., [NAME] Employee E16 confirmed she failed to wash her hands in between soiled and clean dishes. During an interview on 12/18/24, at 12:20 a.m., Dietary Manager Employee E7 confirmed the facility failed to properly restrain hair in hair nets and beard guards and failed to prevent cross contamination by not washing hands in between soiled and clean dishes. During an observation of the First Floor nutrition room on 12/17/24, at 2:08 p.m., the following was observed: -A glass [NAME] jar with what appeared to be soup in it, with no name and no date. 396003 Page 16 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0812 -A partially consumed bottle of strawberry lemonade, with no name and no date, that felt swollen. Level of Harm - Minimal harm or potential for actual harm -A take-out food container with a resident room number on it, with no date. -One large box of rice cereal, open and undated. Residents Affected - Many -One large box of raisin bran cereal, open and undated. -Two bags of tortilla chips, open and undated, with only the top of the bag folded over. -One package of chocolate sandwich cookies, open to air, with no name or date. During an interview on 12/20/24, at approximately 1:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to restrain hair and failed to perform handing washing to prevent the potential for cross contamination in the Main Kitchen and failed to properly label food items in one of two nutrition rooms. 28 Pa. Code: 211.6 (c) (f) Dietary services. 396003 Page 17 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of six residents (Resident R106 and R42). Findings include: Review of facility policy Charting and Documentation dated 3/15/2024, indicated Documentation of procedures and treatments shall include care-specific details and shall include at a minimum, whether the resident refused the procedure/treatment, signature, and title of individual documenting. Review of Resident R106's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R106's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/24, indicated diagnoses of pressure ulcer (PU) of sacral region, pressure ulcer of left hip (open wound with tissue damage), paraplegia (paralysis of the lower half of the body) and severe protein calorie malnutrition (not enough protein and calories are consumed and/or metabolized). Review of a physician order dated 11/12/24, cleanse left hip with NSS and pack with Dakins solution and apply santyl and cover with optifoam dressing every day shift and PRN for unstageable PU. Review of Resident R106's Treatment Administration Record (TAR), daily entires from 12/1/24 through 12/18/24, revealed no entries made for the left hip treatment on 12/2, 12/5, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/15. Review of a physician order dated 12/9/24 cleanse left buttock with NSS and apply Xeroform and cover with optifoam dressing every day shift and PRN for abrasion. Review of Resident R106's Treatment Administration Record (TAR), daily entires from 12/1/24 through 12/18/24, revealed no entries made for the left buttock treatment on 12/11, 12/13, and 12/15. During an interview on 12/19/24 at 1:45 p.m., The Director of Nursing (DON) confirmed the above findings and that the facility failed to make certain that medical records were complete and accurately documented for one of four residents (Resident R106). Review of Resident R42's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R42's MDS dated [DATE], included diagnoses of hemiplegia (paralysis on one side of the body) and post-surgical infection. Review of hospital discharge paperwork dated 6/18/24, indicated the removal of Resident R42's gastrostomy tube (a feeding tube inserted through the wall of the abdomen directly into the stomach). Review of Resident R42's physician and nurse practitioner progress notes from July 2024, through 396003 Page 18 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0842 December 2024, included information of current nighttime tube feedings in each of the notes. Level of Harm - Minimal harm or potential for actual harm During a interview on 12/19/24, at 1:00 p.m., the DON confirmed that the provider progress notes failed to accurately represent Resident R42's current health status. Residents Affected - Some During an interview on 12/20/24, at approximately 1:00 p.m., the Nursing Home Administrator and the DON confirmed that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of six residents. 28 Pa. Code: 211.5(f) Clinical records. 396003 Page 19 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records and staff interview, it was determined that the facility failed to maintain hospice records for three out of five residents receiving hospice services (Resident R2, R72, and R92). Findings include: The facility Hospice Services Agreement policy dated 8/28/23, indicated that the facility will participate in hospice care as an approach for terminally ill residents. The facility must ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility. Review of facility policy Hospice Program reviewed 3/15/24 and 11/1/24, indicated hospice services are available ro residents at the end of life. Collaborating with hospice representatives and coordinating staff participation in the hospice care planning, communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions to ensure quality of care for the resident, and ensuring the facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians. The following information must be obtained from the hospice service: -the most recent plan of care, specific to each resident. -hospice election form -physician certification and recertification of the terminal illness specific to each resident -names and contact information for hospice personnel involved in the hospice care of each resident -instructions on how to access the hospice's 24 hour on-call system -hospice medication information -hospice physician and attending physician (if any) orders specific to each resident. Review of Resident R2's admission record indicated she was admitted on [DATE]. Review of Resident R2's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/9/24, indicated she had diagnoses that included Cerebral Palsy (group of neurological disorders that affect a person's ability to move, maintain balance, and control their muscles). The MDS assessment Section O-0110 Special treatments indicated an x for hospice services. Review of Resident R2's care plan dated 12/1/24, indicated she had hospice services. Review of Resident R2's physician order dated 11/9/24, indicated to admit to hospice. 396003 Page 20 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0849 Review of a practitioner progress note dated 12/9/24, indicated Resident R2 is on hospice services. Level of Harm - Minimal harm or potential for actual harm Review of Resident R2's hospice records did not include the hospice election documentation signed by Resident R2's Representative, hospice visit documents after 11/9/24, and hospice plan of care documents dated after 11/9/24. Residents Affected - Some Reivew of Resident R72's admission record indicated she was admitted on [DATE]. Review of Resident R72's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (group of symptoms affecting memory, thinking and social abilities), and anxiety. Review of Resident R72's physician order dated 10/21/24, indicated admit to hospice. Review of Resident R72's care plan dated 7/17/23, indicated she had hospice services. Review of Resident R72's hospice record did not include the hospice election documentation signed by Resident R72 or representative, hospice visit documentation, medications, hospice providers, and current hospice plan of care. Reivew of Resident R92's admission record indicated he was admitted on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia and hemiplegia (paralysis of one side of the body) following cerebral infarction (blood flow to the brain is obstructed by a blood clot resulting in death of brain cells) affecting left side. Review of Resident R92's physician order dated 8/30/24, indicated admit to hospice. Review of Resident R92's care plan dated 10/18/24, indicated he had hospice services. Review of Resident R92's hospice record did not include the hospice election documentation signed by Resident R92 or representative, hospice visit documentation, medications, hospice providers, and current hospice plan of care. During an interview on 12/20/24, at 12:30 p.m. the Director of Nursing (DON) confirmed that the facility failed to maintain hospice records for Residents R2, R72, and R92 as required. 28 Pa Code: 211.5(f)(h) Clinical records. 28 Pa Code: 211.12 (d)(3)(5) Nursing services. 396003 Page 21 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0941 Level of Harm - Potential for minimal harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for four of ten staff members (Employee E9, E10, E11, E12). Findings include: Review of the facility policy, In-Service Training dated 11/1/24, indicated all staff are required to participate in regular in-service education. Review of the facility ' s previous policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on Effective Communication. Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Effective Communication in-service education between 7/5/23, and 7/5/24. NA Employee E10 had a hire date of 10/20/22, failed to have Effective Communication in-service education between 10/20/23, and 10/20/24. Registered Nurse Employee E11 had a hire date of 9/15/14, failed to have Effective Communication in-service education between 9/15/23, and 9/15/24. Licensed Practical Nurse (LPN) Employee E12 had a hire date of 9/25/19, failed to have Effective Communication in-service education between 9/25/23, and 9/25/24. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Effective Communication for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396003 Page 22 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0942 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employee E9, E13, E14, E15). Findings include: Review of the facility policy, In-Service Training dated 11/1/24, indicated all staff are required to participate in regular in-service education. Review of the facility ' s previous policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on Resident Rights. Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Resident Rights in-service education between 7/5/23, and 7/5/24. Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Resident Rights in-service education between 11/29/23, and 11/29/24. LPN Employee E14 had a hire date of 8/25/22, failed to have Resident Rights in-service education between 8/25/23, and 8/25/24. Therapy Employee E15 had a hire date of 10/16/06, failed to have Resident Rights in-service education between 10/16/23, and 10/16/24. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396003 Page 23 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for six of ten staff members (Employee E9, E10, E11, E12, E13, and E14). Findings include: Review of the facility policy, In-Service Training dated 11/1/24, indicated all staff are required to participate in regular in-service education. Review of the facility ' s previous policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have QAPI in-service education between 7/5/23, and 7/5/24. NA Employee E10 had a hire date of 10/20/22, failed to have QAPI in-service education between 10/20/23, and 10/20/24. Registered Nurse Employee E11 had a hire date of 9/15/14, failed to have QAPI in-service education between 9/15/23, and 9/15/24. Licensed Practical Nurse (LPN) Employee E12 had a hire date of 9/25/19, failed to have QAPI in-service education between 9/25/23, and 9/25/24. LPN Employee E13 had a hire date of 11/29/22, failed to have QAPI in-service education between 11/29/23, and 11/29/24. LPN Employee E14 had a hire date of 8/25/22, failed to have QAPI in-service education between 8/25/23, and 8/25/24. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on QAPI for six of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396003 Page 24 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0946 Provide training in compliance and ethics. Level of Harm - Potential for minimal harm Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of ten staff members (Employee E9 and E13). Residents Affected - Some Findings include: Review of the facility policy, In-Service Training dated 11/1/24, indicated all staff are required to participate in regular in-service education. Review of the facility ' s previous policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on Compliance and Ethics. Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Compliance and Ethics in-service education between 7/5/23, and 7/5/24. Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Compliance and Ethics in-service education between 11/29/23, and 11/29/24. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Compliance and Ethics for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396003 Page 25 of 26 396003 12/20/2024 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146
F 0949 Level of Harm - Potential for minimal harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employee E9, E13, and E15). Findings include: Review of the facility policy, In-Service Training dated 11/1/24, indicated all staff are required to participate in regular in-service education. Review of the facility ' s previous policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment. Review of facility provided documents and training records revealed the following staff members did not have documented training on Behavioral Health. Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Behavioral Health in-service education between 7/5/23, and 7/5/24. Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Behavioral Health in-service education between 11/29/23, and 11/29/24. Therapy Employee E15 had a hire date of 10/16/06, failed to have Behavioral Health in-service education between 10/16/23, and 10/16/24. During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Behavioral Health for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 396003 Page 26 of 26

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Citations

19 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0575GeneralS&S Cno actual harm

    F575 - The facility must post, in a form and manner accessible and understandable

    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

  • 0577GeneralS&S Cno actual harm

    F577 - The resident has the right to-

    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  • 0579GeneralS&S Cno actual harm

    F579 - The facility must display in the facility written information, and provide to

    Provide information about how to apply for and use Medicare and Medicaid benefits.

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    Honor 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.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0725GeneralS&S Epotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0809GeneralS&S Epotential for harm

    F809 - Frequency of Meals

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0849GeneralS&S Epotential for harm

    F849 - Hospice services

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0941GeneralS&S Bno actual harm

    F941 - Training Requirements

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  • 0942GeneralS&S Bno actual harm

    F942 - Training Requirements

    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  • 0944GeneralS&S Bno actual harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0946GeneralS&S Bno actual harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Bno actual harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

FAQ · About this visit

Common questions about this visit

What happened during the December 20, 2024 survey of MONROEVILLE POST ACUTE?

This was a inspection survey of MONROEVILLE POST ACUTE on December 20, 2024. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MONROEVILLE POST ACUTE on December 20, 2024?

Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.