Monroeville Post Acute

Inspectors wroteBased on review of facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of eight residents reviewed (Resident R1).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to provide a clean and comfortable environment in one of twelve resident rooms (Resident 100) and one of two unit lounges (second floor).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to prominently display and maintain facility daily nurse staffing hours as required for eight of eight days 2/24/26 through 3/3/26)

Inspectors wroteBased 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 two of four medication carts (First Floor-South/East Hall, Second Floor-South/East Hall).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed for hospitalization (Resident R6, R27, and R116).

Inspectors wroteBased on a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered care plans for two of eight residents (Resident R11 and R27).

Inspectors wroteBased on review of 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 14 of 20 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10. R11, R12, R13, and R14).

Inspectors wroteBased on review of clinical record was determined that the facility failed to develop a person-centered care plan related to falls for one of five residents (Residents R15). This was identified as past non-compliance.

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies and facility provided documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a facial laceration requiring two sutures for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, and staff interviews it was determined that the facility failed to institute corrective actions and resolve resident grievances for seven of fifteen residents (Resident R2, R3, R4, R5, R6, R7, and R8).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate possible abuse and/or neglect for two of four residents.

Inspectors wroteBased on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide necessary services to maintain grooming and personal hygiene for nine of 16 residents (Residents R2, R3, R4, R5, R6, R7, R8, R20, and R23).

Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to accurately document meal consumption for two of two residents observed. (Residents R9 and R10).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for one of four residents (Resident R122).

Inspectors wroteBased on a review of facility policy, clinical record, and staff and family interviews, it was determined that the facility failed to provide medically-related social services related to a resident transfer for one of three residents (Resident R11).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of three two of seven medication carts (First-floor medication cart for rooms 100-117)

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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). 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a dignified dining experience to the residents during the lunch meal service on October 15, 2024, as required.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a method for resident visitors to easily access the facility to permit visitation of the resident during off hours (Saturday 10/26/24). as required.

Inspectors wroteBased on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman office of residents transfers and discharges for 42 of 42 months (3/21, 4/21, 5/21, 6/21, 7/21, 8/21, 9/21, 10/21, 11/21, 12/21, 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 5/24, 6/24, 7/24, 8/24 and 9/24) as required.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide the residents with a homelike environment in room [ROOM NUMBER], the second floor Dining Room, the first floor resident lounge, and the second floor resident lounge. (room [ROOM NUMBER], Second floor Dining Room, First Floor resident lounge, and second floor resident lounge).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain in proper working order equipment used for two of two methods for visitors to gain entrance to the facility during off hours. (Intercom system and Telephone system)

Inspectors wroteBased on a review of facility records and staff interviews it was determined that the facility failed to notify the resident's responsible party of two of two room changes (Resident R2) as required.

Inspectors wroteBased on a review of facility policies, documents and resident and staff interviews, it was determined that the facility failed to properly complete the grievance process for two of two resident allegations regarding the misappropriation of the resident's personal property. (Resident R1 and R3).

Inspectors wroteBased on review of facility provided policies and documentation, clinical record review, and staff interviews, it was determined that the facility failed to protect residents from neglect of services for seven of 14 residents (R1, R2, R3, R4, R5, R6, and R7). Review of the facility policy Abuse Prohibition dated 7/24/24, previously reviewed 3/11/24, indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of property, and exploitation. The policy defined neglect as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility provided Wound Care Report dated 7/22/24, had handwritten notes on it. During an interview on 8/4/24, at 1:45 p.m. [...]

Inspectors wroteBased on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of wounds for three of seven residents (Resident R1, R3, and R4). The facility policy Skin Integrity and Wound Management dated 7/24/24, previously reviewed 3/11/24, indicated the facility will provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Review of the facility provided Wound Care Report dated 7/22/24, had handwritten notes on it. During an interview on 8/4/24, at 1:45 p.m. Wound Care Nurse Employee E1 stated that the report is the results of the wound rounds on 7/22/24; [...]

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents (Resident R1 and R2).

Inspectors wroteBased 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 13 of 15 residents (Residents R6, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20). Findings Include: Review of the facility policy Staffing/Center Plan dated 7/24/24, previously reviewed 3/11/24, indicated centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. During an interview on 8/4/24, at 3:30 p.m. Resident R6, when asked if she felt the facility maintained sufficient staff, stated, If they show up. [...]

Inspectors wroteBased on a review of facility policy and documents, observation, and interviews, it was determined the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours.

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to schedule ordered appointments for three of five residents (Resident R1, R2, and R3).

Inspectors wroteBased on a review of facility documents, invoices, account payable ledgers, vendor account receivable ledgers, and vendor and staff interviews, it was determined that the facility failed to pay invoices from their transportation vendor for six of six months (10/23, 11/23, 12/23, 1/24, 2/24, and 3/24) which caused the transportation vendor to terminate transport services to the residents.

Inspectors wroteBased on review of facility policy, facility provided information, clinical record, observation and staff interviews it was determined that the facility failed to consistently maintain resident safety during a transfer resulting in a laceration of the left leg for one of three residents (Resident R1)

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to display the contact information (name, address, email address, and phone number) for the local State Survey Agency and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for six of six resident information areas (first floor elevator area, internet cafe, 100 unit, second floor elevator area, resident lounge, and 200 unit).

Inspectors wroteBased on a review of facility policy, observations, and staff interview, it was determined the facility failed to identify the current grievance official who is responsible for overseeing the grievance process necessary to take immediate action to prevent further potential violations of any resident right at six of six posting areas (first floor elevator area, internet cafe, 100 unit, second floor elevator area, second floor resident lounge, and 200 unit.)

Inspectors wroteBased on a review of facility policy, resident record reviews, and staff interviews, it was determined the facility failed to provide fundamental care and treatment in accordance with professional standards of practice to ensure each resident will meet the highest practicable level of physical, mental, and psychological well-being by failing to follow physician orders for nutritional services for one of two residents (Resident R53), and failed to document wound care for four of seven residents with pressure ulcers (Residents R55, R71, R103 and R217) and failed to follow a physicians order to send one of four residents to a follow up appointment (Resident R71).

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident R26). Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/9/23 included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section J: Health Conditions revealed resident R26 is on a scheduled pain medication regimen. [...]

Inspectors wroteBased on review of facility policy, resident records and staff interviews, it was determined the facility failed to maintain complete and accurate dialysis communication forms and failed to maintain ongoing communication with the dialysis center (an outpatient treatment center for those with chronic kidney failure) for three of six residents. (Residents R20, R62, and R600).

Inspectors wroteBased on review of the clinical record and staff interview, it was determined that the facility failed to provide documentation that it acted on the pharmacy recommendations two of five residents (Resident R26 and R92).

Inspectors wroteBased on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) for ten of twelve months(April 2023 through January 2024).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on resident protection from abuse and neglect for 13 of 15 staff members (Employees E7, E8, E9, E10, E12, E13, E14, E15, E16, E17, E18, E19, and E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on infection control procedures for six of ten staff members (Employees E12, E13, E14, E17, E18, and E19).

Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of five nurse aides (Employees E12, E13, E14, and E15).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a clean and homelike environment in one of two shower rooms(Second floor) and for two of four residents( Resident R83 and R84).

Inspectors wroteBased on a observation and staff interview, it was determined that the facility failed to provide a safe environment for residents in one of two resident lounges/activity areas (second-floor activity room).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to make certain that all of the required members were in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters, and failed to provide sign in sheet for QAPI Committee meetings for four of five meetings held (April 2023, May 2023, August 2023 and October 2023).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aide (NA Employee E11, E12, E13, E14, and E15).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for seven of eight staff members (Employees E12, E13, E14, E15, E18, E19, and E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on resident rights for nine of ten staff members (Employees E11, E12, E13, E14, E15, E17, E18, E19, and E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on QAPI (quality assurance and performance improvement) for nine of ten staff members (Employees E12, E13, E14, E15, E16, E17, E18, E19, and E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on compliance and ethics for four of ten staff members (Employees E12, E13, E14, and E19).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on behavioral health for six of ten staff members (Employees E12, E13, E14, E15, E16, and E19).

Inspectors wroteBased on a review of facility personnel files and staff interviews it was determined that the facility failed to employ a qualified full time Food Service Director for four of four months.

Inspectors wroteBased on a review of facility policies, three week Fall/ Winter cycle menu, menu postings and staff interviews it was determined that the facility failed to properly plan and post a cycle menu with alternative selections of equal nutrient value and to have a Registered Dietitian review and approve the three week cycle menu prior to implementation for three of three weeks of the cycle menu (Week one, Week two, and Week three of the Fall/ Winter cycle menu).

Inspectors wroteBased on a review of facility documents, observations and staff interviews it was determined that the facility failed to maintain equipment vital to the operation of the facility in proper work condition in the Main Kitchen and Laundry. (Main Kitchen, Laundry)

Inspectors wroteBased 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 25 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17). Findings Include: Review of the facility policy Staffing/Center Plan dated 8/7/23, indicated centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. During an interview on 10/28/23, at 1:02 p.m. Resident R1, when asked if call lights took a long time to be answered, stated, I have to wait a lot. During an interview on 10/28/23, at 1:02 p.m. [...]

Inspectors wroteBased on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent avoidable falls for one of five residents reviewed (Resident R5).