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F0585
E

Failure to Document and Follow Up on Resident Grievances

Monroeville, Pennsylvania Survey Completed on 12-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document and/or follow up on grievances and concerns presented by staff and residents for five residents. According to the facility's grievance policy, all grievances should be addressed promptly, with written notice of outcomes provided to the resident or their representative. However, review of grievance forms for five residents revealed that the sections indicating whether the resident or their representative was informed of the resolution, and the name of the person informed, were left blank in each case. These grievances included concerns about not receiving showers, not receiving fresh water, being left in a wheelchair, and not receiving incontinence care. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not document or follow up on these grievances as required. The lack of documentation and follow-up was consistent across all five reviewed cases, indicating a failure to comply with both facility policy and regulatory requirements regarding resident rights and grievance procedures.

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