Deficiency Records for Monroeville Rehabilitation and Wellness Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Monroeville Rehabilitation and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-01-11 | 2024-02-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-02-20 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-01-11 | 2024-02-20 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-11-21 | 2023-12-12 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-26 | 2023-08-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-23 | 2023-07-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-23 | 2023-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-23 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-23 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-23 | 2023-07-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-23 | 2023-07-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-23 | 2023-07-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-06-23 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-23 | 2023-07-28 | N |
| 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. | Health | 2023-06-23 | 2023-07-28 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-10 | 2023-05-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-10 | 2023-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-14 | 2023-04-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-14 | 2023-04-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-14 | 2023-04-13 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-26 | 2023-02-27 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-01-26 | 2023-02-27 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-01-26 | 2023-02-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-26 | 2023-02-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-14 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-14 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-14 | 2022-11-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-31 | 2022-09-24 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-08-31 | 2022-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-29 | 2022-09-01 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-14 | 2022-08-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-14 | 2022-08-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-14 | 2022-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-14 | 2022-08-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-14 | 2022-08-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-14 | 2022-08-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-14 | 2022-08-11 | N |
| 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. | Health | 2022-07-14 | 2022-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-14 | 2022-08-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-07-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-23 | 2022-07-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-23 | 2022-07-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-30 | 2022-06-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-30 | 2022-06-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-31 | 2022-04-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-28 | 2022-01-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-20 | 2021-10-15 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-01-25 | 2021-02-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-22 | 2021-02-24 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-01-22 | 2021-02-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-01-22 | 2021-02-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-01-22 | 2021-02-24 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-01-22 | 2021-02-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-01-22 | 2021-02-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-22 | 2021-02-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-01-22 | 2021-02-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-01-22 | 2021-02-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-01-22 | 2021-02-24 | N |
