Monroeville Post Acute

In the surveyor’s words

From the most serious findings on record at Monroeville Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Oct 4, 2022

  Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of sixteen residents (Resident R1 and R2), which caused an organ transplant anti-rejection medication not to be administered. This failure resulted in an Immediate Jeopardy situation for one of sixteen residents (Resident R1). Findings include: Review of facility policy Medication and Treatment Administration Guidelines, Long-Term Care [DATE], indicated staff will ensure that all medications and biological orders are written, dated and signed by the person lawfully authorized to give such an order. […]

• Immediate jeopardy, isolatedF684Mar 12, 2021

  Based on review of clinical records, facility documents and staff interviews, it was determined that the facility failed to provide care and services after an unwitnessed fall, and the facility failed to give the physician an accurate physical assessment to include description of the fall and that the resident was on anticoagulant medication (blood thinner). This failure placed the resident in an Immediate Jeopardy situation for one of four residents reviewed (Closed Record Resident CR1). Findings include: Review of facility policy dated [DATE], Clinical Services Post Fall Evaluation FYI, indicated that, a comprehensive clinical assessment is completed by a nurse supervisor, is important to determine extent of the injury and the need for additional intervention. […]

• Actual harm, isolatedF600May 16, 2025

  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 [DATE]. […]

• Actual harm, isolatedF689May 16, 2025

  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 [DATE]. […]

• Actual harm, isolatedF689Feb 13, 2025

  Based 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). 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) . […]