Wecare Monroeville: Resident Left in Feces 18 Hours - PA

The odor was so strong and foul that LPN Employee E2 knew the dementia patient needed immediate attention. Fifteen minutes later, when a nursing assistant called her back into the room, she discovered the full scope of the neglect.

Resident R15 sat in an "extremely saturated brief that was so deplorable the front of the brief was brown." The bed sheets beneath him were stained brown. The smell was overwhelming.

The resident told staff he hadn't been changed since 2 p.m. the previous day — more than 18 hours earlier.

"It was that bad!" the LPN wrote in her statement about the December 17 incident at Wecare at Monroeville Rehabilitation and Nursing Center.

The LPN immediately called both the night supervisor and daylight supervisor to witness the conditions. The night supervisor confirmed that both evening and night shifts had adequate staffing coverage.

But this wasn't an isolated incident. Records show the facility had systematically failed to provide incontinence care to multiple residents with dementia and cognitive impairments.

Resident R23, who has moderate cognitive impairment and is always incontinent of bowel and bladder, experienced repeated neglect. Care records revealed a disturbing pattern:

December 17: Documented as "continent" despite obvious incontinence issues. December 18: No bowel or bladder care provided. December 19: No bowel or bladder care provided. December 20: No bowel or bladder care provided.

Therapy Employee E3 discovered the extent of the neglect firsthand. On December 18, she changed Resident R23's brief at 10 a.m. She had been marking his briefs daily that week to track care.

The next morning at 10 a.m., she found him still wearing the same brief, "completely soiled." His clothing and bedding were "beyond soiled, with a notable odor and yellow color."

She had expected normal soiling from one shift. Instead, she found evidence that no one had changed him for 24 hours.

Therapy Employee E3 reported the neglect to the nurse supervisor, administrator, Director of Rehabilitation, Social Services, and Human Resources. Facility records later confirmed that Resident R23 "had not been provided incontinence care multiple times."

The facility's own documentation on December 22 admitted the systematic failure.

Meanwhile, staff were subjecting residents to verbal abuse. On December 3, Nursing Assistant Employee E9 called Resident R25 a "nosey bitch" while the resident sat in her wheelchair near the side two nurses' station.

Two employees witnessed the verbal attack.

Resident R25 later told investigators she was in the hallway near the nurses' station when she heard the nursing assistant call her the slur. She said she "was surprised and offended" but "did not feel threatened."

The nursing assistant initially denied the incident entirely. In her written statement dated December 3, Employee E9 claimed: "I never called neither person the housekeeper or the resident a bitch."

But other staff members contradicted her denial. Environmental Services Employee E10 wrote that the nursing assistant told her she "wasn't talking about me she was talking about [Resident R25], about the b---- word."

LPN Employee E2 documented that Resident R25 told her directly: "I didn't call [Environmental Services Employee E10] a bitch. I called [Resident R25] a bitch."

The facility's own investigation, completed December 17, concluded that "Resident R25 was called a nosey bitch by NA Employee E9 while sitting in her wheelchair near side 2 nurse's station. Two employees heard the staff member's verbal abuse."

The nursing assistant was terminated immediately.

But the damage extended beyond individual incidents. During an electronic communication on December 29, the Nursing Home Administrator admitted the facility had "failed to protect residents from verbal and emotional abuse and/or neglect for three of twelve residents."

The residents affected by neglect had serious medical conditions requiring careful monitoring. Resident R23 had dementia and a history of stroke, with moderate cognitive impairment that made him unable to advocate for himself. His care plan, initiated September 12, specifically noted "episodes of incontinence related to impaired mobility and cognition."

Resident R25 had diabetes and heart failure — conditions that make patients particularly vulnerable to complications from poor hygiene and stress.

The inspection revealed systematic failures across multiple areas of resident care and protection. Staff falsified documentation by marking residents as "continent" when they were clearly incontinent and requiring assistance. Supervisors failed to ensure basic hygiene care despite having adequate staffing.

The therapy worker's practice of marking briefs exposed the scope of the problem — residents were being left in the same soiled clothing for entire days, developing odors and skin breakdown that should have been immediately obvious to any caregiver.

Federal regulations require nursing homes to protect residents from abuse and provide necessary care for activities of daily living, including toileting and hygiene. Pennsylvania state codes mandate that facilities maintain resident dignity and provide appropriate nursing services.

The December 29 complaint inspection documented violations affecting multiple residents over several weeks. The facility's own records and employee statements confirmed both the incontinence care failures and the verbal abuse incident.

Resident R15, who sat in feces for 18 hours, represents the human cost of these systemic failures. His dementia made him unable to change himself or effectively advocate for basic hygiene care. Staff with adequate coverage chose not to provide it.

The LPN who discovered him described conditions so severe she immediately called two supervisors to witness them. Yet the pattern continued with other residents, suggesting management failures beyond individual staff negligence.

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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