Pennsylvania Department of Health
MONROEVILLE POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MONROEVILLE POST ACUTE
Inspection Results For:

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MONROEVILLE POST ACUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to three complaints and one incident, completed on May 16, 2025, it was determined that Monroeville Post Acute was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

�483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

�483.12(a) The facility must-

�483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based 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).

Findings include:

Review of the facility policy, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 11/1/24, indicated that residents have the right to be free of neglect.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/5/15.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder of that prevents the changing of cartilage to bone), muscle weakness, and repeated falls.

Review of the MDS dated 1/22/25, Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair.

Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital.

Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries.

Review of a facility incident report dated 2/11/25, indicated, "Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time."

Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on.

Review of Resident R1's plan of care for "At risk for falls" initiated on 6/19/18, included an intervention dated 2/12/25, that indicated, "Foot rests on wheelchair when OOB (out of bed)."

Review of Resident R1's Kardex as of 2/12/25, included the instruction of "OOB to personal chair with leg rests."

Review of the document, "Inservice for Positioning" dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1. Nurse Aide (NA) Employee E2 signed that she received this education."

Review of facility provided education documents dated 3/7/25, revealed education provided to staff on the need to use the Kardex for appropriate assistance levels and individual resident safety needs. Nurse Aide (NA) Employee E2 signed that she received this education."

Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, "Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air."

Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, "Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward."

Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, "Resident returned from [hospital] with sutures to forehead and a hematoma."

Review of facility submitted information dated 3/19/25, indicated, " On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions."

Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days.

Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters.

Review of an update to the submitted information dated 3/25/25, indicated, "On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated."

Review of an undated employee statement written by NA Employee E2 indicated, "When I got [Resident R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television."

Review of the "Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property" dated 3/28/25, indicated that NA Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment.

Attempts to call and interview NA Employee E2 were unsuccessful.

During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs.

During an interview on 5/7/15, at 11:50 a.m., NA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs.

During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed NA Employee E2 had two separate educations on the need to use leg rests for Resident R1 and the need to use the Kardex for appropriate assistance levels and safety information, confirmed that NA Employee E2 did not appropriately position Resident R1 in his wheelchair, and confirmed that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1).

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(e)(1) Management.
28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 05/29/2025

Resident R1 safety interventions on Kardex will be confirmed as implemented by Director of Nursing or Designee.

An audit of all current residents' Kardex to be completed by the Director of Nursing or Designee. Any resident with safety interventions listed will be reviewed as implemented by the Director of Nursing or Designee.

Directed in-service to be completed by Masters Crafted in Healthcare in the area of F600 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation and accompanying guidelines. The directed in-service will be held on May 23, 2025

10% of residents with safety interventions listed on their Kardex will be audited for implementation weekly x4 weeks then monthly x2 month by the Director of Nursing or Designee. Audits will be tracked, trended and reported to Quality Assurance Committee for further recommendations or follow-up with Director of Nursing or Designee.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

�483.25(d) Accidents.
The facility must ensure that -
�483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

�483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based 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).

Findings include:

Review of the facility policy, "Supporting Activities of Daily Living (ADL)" dated 11/1/24, indicated "Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/5/15.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder that prevents the changing of cartilage to bone), muscle weakness, and repeated falls.

Review of the MDS dated 1/22/25, Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair.

Review of Resident R1's plan of care for "Requires assistance / potential to restore function for MOBILITY" dated 2/9/23, indicated the intervention of a high back w/c (wheelchair) with fitted leg rests and a foot buddy (a stable platform for the wheelchair user's feet).

Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 2/10/25, did not include information related to the use of a high back wheelchair or a foot buddy.

Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital.

Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries.

Review of a facility incident report dated 2/11/25, indicated, "Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time."

Review of Resident R1's plan of care for "At risk for falls" initiated on 6/19/18, included an intervention dated 2/12/25, that indicated, "Foot rests on wheelchair when OOB (out of bed)."

Review of Resident R1's Kardex as of 2/12/25, included the instruction of "OOB to personal chair with leg rests."

Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on.

Review of the document, "Inservice for Positioning" dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1.

During an interview on 5/7/25, at approximately 2:00 p.m. Director of Therapy Employee E1 confirmed that only eight staff were educated, with the expectation that those staff would disseminate the information to their coworkers.

Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, "Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air."

Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, "Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward."

Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, "Resident returned from [hospital] with sutures to forehead and a hematoma."

Review of facility submitted information dated 3/19/25, indicated, " On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions."

Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days.

Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters.

Review of an update to the submitted information dated 3/25/25, indicated, "On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated."

Review of an undated employee statement written by NA Employee E2 indicated, "When I got [Resident R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television."

Attempts to call and interview NA Employee E2 were unsuccessful.

During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs.

During an interview on 5/7/15, at 11:50 a.m., MA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs.

Review of the "Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property" dated 3/28/25, indicated that Nurse Aide Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment.

During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1).

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 05/29/2025

Resident R1 safety interventions on Kardex will be confirmed as implemented by Director of Nursing or Designee.

An audit of all current residents' Kardex to be completed by Director of Nursing or Designee. Any resident with safety interventions listed will be reviewed as implemented by Director of Nursing or Designee.

Directed in-service to be completed by Masters Crafted in Healthcare in the area of F689 42 CFR 483.25(d) Accidents and accompanying guidelines with follow up education conducted by staff development or designee for nursing staff. The directed in-service will be held on May 23, 2025.

10% of residents with safety interventions listed on their Kardex will be audited for implementation weekly x4 weeks then monthly x2 months by the Director of Nursing or Designee. Audits will be tracked, trended and reported to Quality Assurance Committee for further recommendations or follow-up with the Director of Nursing or Designee.

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