Wecare at Monroeville Rehabilitation and Nsg Ctr

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of eight residents (Resident R1 and R3).

Inspectors wroteBased on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for four of twelve residents (Residents R4, R5, R6, and R7).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care and personal hygiene care for two of four residents (Resident R1 and R2).

Inspectors wroteBased on review of facility documents, clinical record review, observations, and resident interviews, it was determined that the facility failed to ensure a resident with limited mobility received assistance to maintain or improve mobility for one of three residents (Resident R1).

Inspectors wroteBased on observations, resident interviews, staff interviews, review of facility policies and Safety Data Sheets (standardized document that provides detailed information about the hazards, safe handling, storage, and emergency measures for chemical substances or mixtures), and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to have working laundry equipment to ensure clean and sanitized linens/laundry. This failure resulted in an Immediate Jeopardy for 67 of 67 residents in the facility.

Inspectors wroteBased on review of the facility policies, facility submitted data, clinical record and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from verbal and physical abuse which resulted in the harm of Resident R1 to be fearful of staff for one four residents reviewed (Resident R1).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON), failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections from resident-to-resident , which created an Immediate Jeopardy for 67 of 67 residents .

Inspectors wroteBased on review of facility policy, observations, resident interviews, staff interviews, and review of facility documents it was determined that the facility failed to ensure a clean, sanitary, and functional environment in the laundry room.

Inspectors wroteBased on review of facility policy, resident interviews, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free of significant medication errors for two of three residents (Residents R5 and R10).

Inspectors wroteBased on review of facility policy, documents, clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without physical restraint order for one of six residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical record review, facility submitted data, and staff interview, it was determined that the facility failed to report an allegation of abuse in the required timeframe for one of four residents (Resident R1) and failed to report a significant medication error for two of three residents reviewed (Residents R5 and R10) and failed to report the facility's laundry washing machine were not working.

Inspectors wroteBased on review of facility policy, clinical record, staff and family interview, it was determined that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the nutritional concerns for one of five residents (Resident R11).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.

Inspectors wroteBased on observations, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units observed (First and Second Nursing Units). This failure resulted in a harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 26 of 41 residents (Residents R1,R8,R14,R15,R18,R19, R22,R24,R25,R32,R38,R40,R44,R48,R51,R52,R61,R67,R69,R70 R72,R73,R74 R77,R78 ) who were identified as having the physical ability to access hot water outlets in the sinks and/or shower rooms throughout the entire facility.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination and failed to make certain staff wore proper hair restraints in the main kitchen.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on two of four medication carts (medication cart #1 and unused medication cart).

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (Side 1 and Side 2) and failed to provide clean linens, wash cloths and towels to accommodate the needs of the residents of two of two nursing units (Side 1 and Side 2).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify the physician of increased or decreased Capillary Blood Glucose (CBG) levels and failed to assess residents of hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for three of seven residents (R1, R14, and R77).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of two residents reviewed (Residents R1 and R21).

Inspectors wroteBased on review of facility policy, resident observations, resident group interview, a confidential staff interview and staff interviews, 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 twelve of twenty-four residents (Residents R1, R2, R5, R14, R36, R51, R60, and R700 R701, R702 R801, and R802). Findings Include: Review of the facility policy Staffing, Sufficient and Competent Nursing, reviewed on 1/8/26 with a prior review date of 6/1/25, indicated, attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart for one of three medication carts currently in use (Cart #1) and failed to properly secure a medication cart while not in use for one of four medication carts (Cart #4).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for five of twenty-three residents (Resident R40, R51, R700, R701, and R702).

Inspectors wroteBased on review of facility policy, resident council documents, resident group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for seven out of eight months (August 2025, September 2025, October 2025, November 2025, December 2025, February 2026 and March 2026).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of seven residents (Resident R77).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift.

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units observed (First and Second Nursing Units). This failure resulted in a harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 26 of 41 residents.

Inspectors wroteBased on observations, family interview, and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, and functional environment in the laundry room.

Inspectors wroteBased on facility documents, observations, and staff interviews, it was determined that the facility failed to make certain door alarm systems were regularly tested for functionality.

Inspectors wroteBased on review of clinical record review and staff and resident interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of wounds for two of five residents (Resident R4 and R5).

Inspectors wroteBased on review of facility policy, clinical record review, resident interviews and observations, staff interviews, and it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R2 and R3).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to ensure equipment was in safe operating condition for two of two crash carts (carts maintained with equipment used in emergencies, 100-Hall and 2-Hall) and two of two facility dryers. Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], previously dated [DATE], indicated, Maintain equipment and supplies necessary for CPR/BLS (cardiopulmonary resuscitation / basic life support) in the facility at all times.

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased capillary blood glucose (CBG) levels for four of six residents (Resident R1, R2, R3, and R4). The Centers for Disease Control indicated hyperglycemia is blood glucose greater than 125 mg/dL (milligrams per deciliter) while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If hyperglycemia is left untreated for long periods of time, it can damage nerves, blood vessels, tissues and organs. [...]

Inspectors wroteBased on a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for three of 27 licensed nurses (Licensed Practical Nurse (LPN) Employees E10 and E11, and Registered Nurse (RN) Employee E14). Review of the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation dated [DATE], previously dated [DATE], indicated Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS) / Cardiopulmonary Resuscitation (CPR). [...]

Inspectors wroteBased on a review of facility policy and records and staff interviews, it was determined that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 15 of 27 licensed nurses (Licensed Practical Nurse (LPN) Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E12, and Registered Nurse (RN) Employees E13, E15, E16, E17, and E18). [...]

Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population or outcome of the facility assessment for eight of nine staff members sampled (Employees E19, E20, E21, E22, E24, E25, E26, and E27).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of for two of two crash carts (carts maintained with equipment used in emergencies, 100-Hall and 2-Hall).

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to align facility policies with Centers for Medicare and Medicaid Services requirements.

Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document wound care orders and treatments for four of seven residents (Residents R5, R6, R7, and R8).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to accurately complete the Facility Assessment.

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for ten of ten residents reviewed (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in two of two locations (front hallway and rear hallway).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment on two of two nursing units and for seven of twelve residents.

Inspectors wroteBased on review of facility documentation, clinical records, and staff interviews it was determined the facility failed to document and/or follow-up on concerns/grievances presented by staff and residents for five of five residents (Resident R11, R12, R13, R14, and R15).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from verbal and emotional abuse and/or neglect for three of twelve residents (Resident R15, R23, and R25).

Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to follow physician's orders for four of five residents (Resident R16, R17, R18, and R19).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, information submitted to the Pennsylvania Department of Health (PADOH, Resident Council minutes, 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 16 of 35 residents (Residents R1, R5, R11, R12, R13, R14, R15, R16, R17, R20, R22, R26, R27, R30, R31, and R32). Findings Include: Review of the facility policy, Answering the Call Light dated 6/1/25, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to implement policies and procedures to report possible neglect of one of three residents (Resident R23).

Inspectors wroteBased on facility policy, clinical record review, and resident and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of three residents (Resident R13). Findings Include: Review of the facility policy, Laboratory Testing and Result Management dated 6/1/25, indicated, The facility shall ensure that laboratory tests are obtained, processed., reviewed, and acted upon in a timely manner by qualified staff. Review of the clinical record revealed that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 12/1/25, included diagnoses of chronic kidney disease (gradual loss of -kidney function), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and high blood pressure. [...]

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to determine if it was safe to self-administer medications for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for three of ten residents as required (Residents R1, R2, and R3) on two of two nursing units side one and side two.

Inspectors wroteBased on observations, review of facility documentation, resident, and staff interviews, it was determined that the facility failed to make certain that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for three of ten residents (Residents R1, R2, and R3).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one AEDs (Automatic External Defibrillators).

Inspectors wroteBased on review of facility policies, observations, and staff interviews it was determined that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner for one of four nursing medication carts (100 Hall) and failed to label multi-dose vials and check expiration dates for two of four nursing medication carts (100 and 200 Hall).

Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined that the facility failed to complete education regarding, Coronavirus Disease (COVID) vaccination for three of five residents (R9, R18, R50), influenza vaccination education for two of five residents (R32, R50) and pneumococcal vaccination education for five of five residents (R9, R18, R32, R36, R50).

Inspectors wroteBased on review of facility policy and documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain that showers and baths were provided for three of five residents (Resident R1, R2, and R3).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of two residents (Resident R1). This failure created an immediate jeopardy situation for 19 of 91 residents. This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. [...]

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 an elopement for one of two residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Abuse and Neglect - Clinical Protocol dated 1/22/25, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify resident representative and/or medical providers of a newly ordered medication or a change in condition for three of seven residents (Resident R10, R11, and R2).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for four of eight residents (Residents R7, R18, R19, and R20).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of five residents (Resident R4 and R5).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents (Resident R5 and R6).

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 ten of 18 residents (Residents R4, R5, R12, R13, R14, R15, R16, R17, R18, and R19). Findings Include: Review of the facility policy Answering the Call Light dated 1/22/25, indicated staff will ensure timely responses to the resident's requests and needs. During an observation on 3/26/25, at 3:39 p.m. the call light for Residents R19 was alarming. At this time, six nursing staff members were noted to be seated at the nursing station, without responding. When staff observed the surveyor noting the time, Nurse Aide Employee E13 responded to the call light. [...]

Inspectors wroteBased on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document physician notification for three of eight residents (Residents R7, R8, and R9).

Inspectors wroteBased on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 18 of 91 residents.

Inspectors wroteBased on review of facility documents, observations and staff interview, it was determined that the facility failed to maintain an effective call system for three of five restrooms accessible to residents.

Inspectors wroteBased on a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents (Resident R11).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for 8 of 19 Residents (Residents R3, R9, R54, R55, R59, R61, R66, R187).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of in one of two supply rooms (100-Unit supply room ).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of seven residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 6/1/23, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on a review of facility policy, grievance reviews, facility provided documents, resident records, and resident and staff interviews, it was determined the facility failed to protect residents from misappropriation of resident property for three of three residents (Residents R2, R3 and R5).

Inspectors wroteBased on a review of facility policy, observations, resident record review, and resident and staff interviews, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment for one of four residents (Resident R2).

Inspectors wroteBased on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that the residents were aware of unrestricted visitation.

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for five of nine residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on a review of facility documents, personnel records, and staff interview, it was determined that the facility failed to employ a qualified social worker for one of two employees (Employee E1).

Inspectors wroteBased on review of staff interview and facility documents, it was determined that the facility failed to provide training on behavioral health for 16 of 38 staff members reviewed (E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, and E16). Findings Include: Review of the facility policy Staff Development dated 6/1/23, indicated All employees receive Inservice annually and as needed. Annual training will include Psychosocial Needs, Dementia, Trauma Informed Care, and Substance Use Disorder. During nine staff interviews conducted on 11/19/23, between 1:00 p.m. and 3:00 p.m. the following was indicated: Nurse Aides (NA) Employees E1 and E2 stated they had just begun working at the facility within the previous few days, and had not been provided behavioral health or dementia training from the facility. [...]