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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, facility policy and staff interviews, it was determined that the facility failed to provide a safe,
clean, comfortable, and homelike environment on one of one nursing units (second floor nursing
unit).Findings included:Review of the facility policy Housekeeping Homelike Environment dated 4/14/25,
indicated residents are provided with a clean and homelike environment.During an observation on 10/8/25,
at 9:40 a.m., the following was observed:room [ROOM NUMBER] had black skid marks all over floor tiles
and the floor appeared soiled.room [ROOM NUMBER] had cracks in tiles at entrance of room.room [ROOM
NUMBER] had multiple cracked floor tiles.During an interview on 10/8/25 at 10:26 a.m., the Nursing Home
Administrator was made aware of areas and confirmed that the facility failed to provide a safe, clean,
comfortable, and homelike environment on one of one nursing units (second floor nursing unit).28 Pa.
Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.
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
12/03/2025
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)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of facility policy, observations, and staff interview, it was determined the facility failed to maintain a
fully functioning resident call bell system that allows residents to call for staff assistance through a
communication system on one of one nursing units (second floor nursing unit). Findings include: Review of
the facility policy Call Light dated 4/14/25, indicated, residents will have a call light or a bell to allow patients
to call for assistance. If call bell is defective, it is reported immediately. During an observation on 10/8/25 at
9:43 a.m. the central call light was activated in the North Hall however, there were no resident room lights
illuminated above doors.During an observation on 10/8/25, at 9:46 a.m., resident room [ROOM NUMBER]
call light was illuminated above the door, however, the central hall light for the South Hall was not
illuminated.During an observation on 10/8/25, at 9:53 a.m., resident room [ROOM NUMBER] call light was
illuminated above the door, however, the central hall light for the [NAME] Hall was not illuminated.During an
interview on 10/8/25, at 10:18 a.m., the Maintenance Director Employee E1 confirmed that the confirmed
that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for
staff assistance through a communication system on the second-floor nursing unit. 28 Pa Code 207.2(a)
Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396085
If continuation sheet
Page 2 of 2
