Resident R13 saw a dermatologist on December 10th who determined his psoriasis wasn't responding to topical treatments. The consultation report stated blood work was "ordered today" and "needs the labs completed prior to starting the medication."
Nothing happened.
Five days later, on December 15th at 2:00 p.m., the resident asked staff about his bloodwork. A progress note documented the exchange: "This nurse asks RN to see if any such orders exist and RN couldn't locate any orders. RN supervisor went and spoke with resident regarding this situation."
The next day, staff from the dermatology office called WeCare at Monroeville Rehabilitation and Nursing Center. They told facility staff that labs were ordered and "must be completed prior to starting the medication." Only then did the facility generate a physician's order for the required tests on December 16th.
The order specified four blood tests: a liver function panel, tests for hepatitis B and C immunity, and screening for tuberculosis infection. The order was active for three days, from December 18th through December 21st.
Staff drew blood on December 18th. But when inspectors reviewed the laboratory results, they discovered the blood tests were "related to an unrelated laboratory order" — not the tests the dermatologist had ordered for the psoriasis medication.
A progress note from December 25th confirmed lab work was drawn on December 18th, but inspection records show "the clinical record failed to reveal documentation that the blood tests were completed."
During interviews with federal inspectors, three separate confirmations emerged that the required tests were never done. On December 22nd, the nursing home administrator confirmed "the blood tests were not completed." The next day, Resident R13 told inspectors "the blood tests were not yet completed."
Six days later, during the inspection on December 29th, both the resident and administrator gave identical confirmations. At 2:00 p.m., Resident R13 confirmed "the blood tests were not yet completed." Forty-five minutes later, the administrator told inspectors electronically that "the facility failed to obtain laboratory services as ordered."
The resident's medical conditions made the delay particularly concerning. His December assessment documented chronic kidney disease, heart failure, and high blood pressure alongside the uncontrolled psoriasis that had brought him to the dermatologist.
Facility policy required timely laboratory services. The June 2025 Laboratory Testing and Result Management policy stated: "The facility shall ensure that laboratory tests are obtained, processed, reviewed, and acted upon in a timely manner by qualified staff."
The breakdown occurred across multiple levels. The initial dermatologist order from December 10th never generated facility action. When the resident asked about his bloodwork five days later, nursing staff couldn't locate any orders. When the dermatology office called to remind staff about the required tests, it took another day for the facility to create a physician's order.
Even after staff drew blood on the correct date, they processed the wrong tests. The December 18th blood draw addressed different medical needs entirely, leaving the dermatologist's requirements unfulfilled.
The systemic medication the dermatologist prescribed remained unavailable to Resident R13 throughout the inspection period. Federal inspectors documented the case as part of broader concerns about laboratory service management at the facility.
Progress notes revealed gaps in documentation surrounding the incident. Inspectors found "no notes dated 12/10/25, through 12/14/25" in Resident R13's record, spanning the critical period between the dermatologist consultation and the resident's inquiry about his missing bloodwork.
The facility's failure affected treatment for a chronic condition that causes red, itchy, scaly skin patches. The dermatologist had determined topical treatments were insufficient and systemic medication was necessary, but facility delays prevented the resident from accessing the prescribed treatment.
During the final inspection interview on December 29th, nearly three weeks after the dermatologist's initial order, Resident R13 was still waiting for the blood tests that would allow his new psoriasis medication to begin.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wecare At Monroeville Rehabilitation and Nsg Ctr from 2025-12-29 including all violations, facility responses, and corrective action plans.
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