Inspection·August 3, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood) center for one of three residents reviewed (Resident R16), and failed to reveal a complete physician order for dialysis for two of three (Residents R16 and R32 ), and failed to reveal a physician order for care of the dialysis access site (allows vascular access in adult patients requiring dialysis) for two of three residents (Residents R16 and R32). Residents Affected - Some Findings include: A review of the facility policy Hemodialysis dated 3/8/23, indicated the facility will ensure the physician orders for dialysis include the type of access for dialysis and location, and the dialysis schedule. Documentation requirements are provided to assure that treatments are provided as ordered by the physician and there is ongoing communication and collaboration between the facility and dialysis staff. Residents with external access sites will be assessed every shift to ensure the site dressing is intact and not soiled. Change the dressing to the site only per the dialysis facility's direction. A review of the clinical record face sheet indicated Resident R16 was admitted to the facility on [DATE], and has a diagnosis of End Stage Renal (kidney) Disease and is dependent on dialysis. A review of the MDS (Minimum Data Set-resident assessment and care screening) dated 6/2/23, indicated Resident R16 receives dialysis and is alert and oriented times three and able to make needs known. A review of Resident R16's care plan revised 3/31/23, indicated the resident receives dialysis and has a left arm fistula (dialysis access site). A review of a physician order dated 1/20/23, indicated a standing order for dialysis, but did not include the type of dialysis access, care of the dialysis access, or the dialysis schedule. A review of a progress note dated 6/9/23 and 6/15/23, indicated the resident receives dialysis. A review of a progress note dated 7/19/23, indicated the resident was at dialysis. During an observation and interview with Resident R16 on 8/1/23 at 11:00 a.m., revealed a dialysis access site to the upper left arm covered with a dry dressing. Resident R16 stated I go to dialysis every Monday, Wednesday and Friday. A review of a the Dialysis Communication Records indicated the resident received dialysis on 7/5, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 396085 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mon Valley Care Center 200 Stoops Drive Monongahela, PA 15063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)