Wecare At Monroeville Rehabilitation And Nsg Ctr
WECARE AT MONROEVILLE REHABILITATION AND NSG CTR in MONROEVILLE, PA — inspection on December 29, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based 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).Findings include: The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities.
However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities.
These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor.
This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents.
During an observation on 12/23/25, at 9:42 a.m. of the grievance box near the 100-unit nurses' station in the rear hall revealed the opening for grievance forms to be 57 inches from the floor.
During an observation on 12/23/25, at 9:46 a.m. of the grievance box near the facility entry way in the front hall revealed the opening for grievance forms to be 57 inches from the floor.
During an electronic interview on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents in two of two locations. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Based 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.Findings include: Review of the facility policy Homelike Environment dated 6/1/25, indicated in part, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include clean bed and bath linens that are in good condition.
Review of information submitted to the Pennsylvania Department of Health on 12/22/25, indicated that Resident R21 had vomited under his bed on 12/18/25, and the dried vomit remained under his bed on 12/22/25.
During an interview on 12/22/25, at 12:59 p.m. the Nursing Home Administrator confirmed that Resident R21's room had not been cleaned of the vomit from 12/18/25.
During an observation on 12/22/25, at 1:50 p.m.
Resident R20's room was noted to have food on the floor with a smell of urine.
During an observation of Resident R24's room revealed blood on the restroom light switch, feces and blood on the bathroom floor and on the commode and sink.
The overbed table was dirty, a large amount refuse on the floor, walls were unclean, and a wall outlet with a loose faceplate and a large gouge in the wall.
Above the outlet was a handwritten sign that said Do Not Use This Outlet with an error pointing down toward the outlet.
During an interview on 12/22/25, at approximately 2:20 p.m. the Environmental Services Supervisor Employee E5 confirmed that he currently only had three housekeepers currently employed.
During an observation on 12/22/25, at 3:44 p.m., Resident R1 was noted to have a soiled brief on his restroom floor and what appeared to be feces on his bed linen.
During an observation on 12/23/25, at 11:52 a.m., Resident R18's room had an overwhelming smell of urine.
During an interview on 12/23/25, at 11:54 a.m., Nurse Aide Employee E4 stated that the urine was imbedded in the mattresses.
During an observation on 12/23/25, at 11:58 a.m., Resident R22's room smelled of urine.
During an observation on 12/23/25, at 12:08 p.m., Resident R23's room was unclean with soiled gloves on the overbed table. A bag of soiled linen was on the floor.
During an electronic interview on 12/29/25, at 2:45 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a clean and homelike environment on two of two nursing units and for seven of twelve residents. 28 Pa.
Code: 207.2(a) Administrator's responsibility. 28 Pa.
Code: 201.29(k) Resident rights.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Based 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).Findings include: Review of facility, Grievance Policy dated 6/1/25, indicated the facility is committed to maintaining transparent, fair, and accessible grievance process.
Every grievance will be addressed promptly and appropriately, in accordance with federal and state regulations.
Residents and their representative must be assured that: They can submit grievances orally or in writing; Their concerns will be investigated and responded to promptly; They will not face discrimination, reprisal, or retaliation; They will receive written notice of grievance outcomes within required timeframes.
Review of a grievance filed by Resident R11 on 11/19/25, reported a concern related to not receiving showers.
The form section that indicated if the resident/resident representative was informed of the resolution and the name of the person informed were blank.
Review of a grievance filed by Resident R12 on 11/20/25, reported a concern related to not receiving showers.
The form section that indicated if the resident/resident representative was informed of the resolution and the name of the person informed were blank.
Review of a grievance filed by Resident R13 on 12/4/25, reported a concern related to not receiving fresh water.
The form section that indicated if the resident/resident representative was informed of the resolution and the name of the person informed were blank.
Review of a grievance filed on behalf of Resident R14 on 12/11/25, reported a concern related to Resident R14 being left in the wheelchair.
The form section that indicated if the resident/resident representative was informed of the resolution and the name of the person informed were blank.
Review of a grievance filed on behalf of Resident R15 on 12/17/25, reported a concern related to Resident R15 not receiving incontinence care.
The form section that indicated if the resident/resident representative was informed of the resolution was blank and the name of the person informed was signed by the Director of Nursing.
During an electronic interview on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to document and/or follow-up on concerns/grievances presented by staff and residents for five of five residents. 28 Pa.
Code 201.29(a) Resident Rights.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], included diagnoses of dementia and history of a stroke.
Review of Section C: Cognitive Patterns indicated that Resident R23 had moderate cognitive impairment.
Review of Section H: Bladder and Bowel indicated that Resident R23 was always incontinent of bowel and bladder.
Review of Resident R23's plan of care initiated 9/12/25, indicated that Resident R23 has episodes of incontinence related to impaired mobility and cognition.
Review of Resident R23's ADL care record for incontinence care revealed the following:12/17/25: Documented as continent12/18/25: No bowel/bladder care provided.12/19/25: No bowel/bladder care provided.12/20/25: No bowel/bladder care provided.
Review of facility submitted information dated 12/22/25, indicated that Resident R23 had not been provided incontinence care multiple times.
During an interview on 12/23/25, at 1:13 p.m.
Therapy Employee E3 stated she had changed Resident R23's brief was changed by her on 12/18/25, at 10:00 a.m.
Therapy Employee E3 stated she had labeled his briefs every day this week, and have found him to be extremely soiled, more than she would expect in one shift. At 10:00 a.m. on 12/19/25, Therapy Employee E3 stated that she discovered that he was still in the same brief, completely soiled.
Resident R23's clothing and bedding were also beyond soiled, with a notable odor and yellow color.
Therapy Employee E3 stated she brought this to the attention of the nurse supervisor, administrator, Director of Rehabilitation, Social Services, and Human Resources.
Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles).
Review of Section C: Cognitive Patterns indicated that Resident R23 had moderate cognitive impairment.
Review of a resident statement dated 12/4/25, indicated, The resident was interviewed and stated that she was in the hallway of the side two nurse's station and heard [NA Employee E9] call her a bitch.
The resident did not react but was surprised and offended.
The resident did not feel threatened.
Review of an employee statement written by LPN Employee E2 dated 12/3/25, indicated, [Resident R25] stated ‘I didn't call [Environmental Services Employee E10] a bitch. I called [Resident R25] a bitch.' Review of an employee statement written by Environmental Services Employee E10 dated 12/3/25, indicated, She said she wasn't talking about me she was talking about [Resident R25], about the b---- word.
Review of an employee statement written by NA Employee E9 dated 12/3/25, indicated, I never called neither person the housekeeper or the resident a bitch.
Review of facility submitted information dated 12/17/25, indicated, [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 employee was immediately terminated.
During an electronic communication on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed the facility failed to protect residents from verbal and emotional abuse and/or neglect for three of twelve residents. 28 Pa.
Code 201.14(a) Responsibility of licensee.28 Pa.
Code 201.18(b)(e)(1) Management.28 Pa.
Code 201.29(a) Resident rights.28 Pa.
Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/15/25, included diagnoses of dementia and history of a stroke.
Review of Section C: Cognitive Patterns indicated that Resident R23 had moderate cognitive impairment.
Review of Section H: Bladder and Bowel indicated that Resident R23 was always incontinent of bowel and bladder.
Review of Resident R23's plan of care initiated 9/12/25, indicated that Resident R23 has episodes of incontinence related to impaired mobility and cognition.
Review of Resident R23's ADL care record for incontinence care revealed the following:12/17/25: Documented as continent12/18/25: No bowel/bladder care provided.12/19/25: No bowel/bladder care provided.12/20/25: No bowel/bladder care provided.
Review of facility submitted information dated 12/22/25, indicated that Resident R23 had not been provided incontinence care multiple times.
During an interview on 12/23/25, at 1:13 p.m.
Therapy Employee E3 stated she had changed Resident R23's brief was changed by her on 12/18/25, at 10:00 a.m.
Therapy Employee E3 stated she had labeled his briefs every day this week, and have found him to be extremely soiled, more than she would expect in one shift. At 10:00 a.m. on 12/19/25, Therapy Employee E3 stated that she discovered that he was still in the same brief, completely soiled.
Resident R23's clothing and bedding were also beyond soiled, with a notable odor and yellow color.
Therapy Employee E3 stated she brought this to the attention of the nurse supervisor, Administrator, Director of Rehabilitation, Social Services, and Human Resources.
Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible neglect to Resident R23.
During an electronic communication on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to report possible neglect of one of three residents. 28 Pa.
Code 201.14(a) Responsibility of licensee.28 Pa.
Code 201.18(b)(e)(1) Management.28 Pa.
Code 201.29(a) Resident rights.28 Pa.
Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Review of the clinical record for Resident R8 revealed the baseline care plan initiated 12/16/25, was incomplete with errors on 12/23/25, eight days after admission.
Review of Resident R9's clinical record reviewed that the resident was admitted to the facility on [DATE].
Review of Resident R9's facility diagnosis list included heart failure and COPD.
Review of the clinical record for Resident R9 revealed the baseline care plan initiated 12/11/25, was incomplete on 12/23/25, 12 days after admission.
Review of Resident R10's clinical record reviewed that the resident was admitted to the facility on [DATE].
Review of Resident R10's facility diagnosis list included throat cancer and COPD.
Review of the clinical record for Resident R10 revealed the baseline care plan initiated 12/20/25, was incomplete on 12/23/25, four days after admission.
During an electronic interview on 12/29/25, at 2:45 p.m., the Nursing Home Administrator confirmed 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 28 Pa Code 211.10(a) Resident care policies.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident R19's December 2025 TAR revealed that LPN Employee E2 documented that Resident R19's left knee splint was applied.
During an interview on 12/23/25, at approximately 1:15 p.m.
Therapy Employee E3 stated that residents not having their splints and braces applied is a large concern and stated that often they don't get applied unless therapy staff to apply them.
During an electronic interview on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to follow physicians' orders for four of five residents. 28 Pa.
Code 211.12(d)(1)(5) Nursing services.28 Pa.
Code 211.12(d)(3) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
During an interview and observation on 12/23/25, at 12:50 p.m.
Resident R26, when asked if the facility maintains enough staff to care for the residents stated, Heck no.
Observation at this time revealed that Resident R26's hair was unbrushed and she remained in a gown at this time.
During an interview on 12/23/25, at 1:08 p.m.
Therapy Employee E12 stated that when meeting with residents, they appear to not have been provided personal care and are unclean and that residents are not being assisted to get out of bed.
During an interview on 12/23/25, at 1:10 p.m.
Therapy Employee E13 stated that when meeting with residents, residents have been in soiled briefs and appear unclean.
Therapy Employee E13 stated it does not appear that residents are being assisted to bathe and are malodorous.
Therapy Employee E13 stated that the facility is understaffed in nurses and nurse aides.
During an interview on 12/23/25, at 1:13 p.m.
Therapy Employee E3 stated that most, if not all, residents are not provided with the care they need, that the facility is really understaffed, that residents are left in bed and in soiled linen, call light response can be hours, and conditions are consistently bad.
Review of Resident Council minutes dated 9/17/25, revealed residents voiced concerns about call light response times and bed linens not being changed consistently.
Review of Resident Council minutes dated 10/15/25, revealed residents voiced concerns about showers not being completed even when requested, nail care not being completed, call light response times, and fresh water not being passed.
Review of Resident Council minutes dated 11/19/25, revealed residents voiced concerns about call light response times, showers not being completed and being told the facility is too understaffed to complete them, and snacks not being passed.
Review of a grievance filed by Resident R11 on 11/19/25, reported a concern related to not receiving showers.
Review of a grievance filed by Resident R12 on 11/20/25, reported a concern related to not receiving showers.
Review of a grievance filed by Resident R13 on 12/4/25, reported a concern related to not receiving fresh water.
Review of a grievance filed on behalf of Resident R14 on 12/11/25, reported a concern related to Resident R14 being left in the wheelchair.
Review of a grievance filed on behalf of Resident R15 on 12/17/25, reported a concern related to Resident R15 not receiving incontinence care.
During an electronic interview on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed 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. 28 Pa.
Code: 201.14(a) Responsibility of licensee. 28 Pa.
Code 201.18(e)(6) Management. 28 Pa.
Code: 201.20(a) Staff development. 28 Pa.
Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wecare at Monroeville Rehabilitation and Nsg Ctr
4142 Monroeville Blvd Monroeville, PA 15146
SUMMARY STATEMENT OF DEFICIENCIES
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.
Review of the plan of care dated 4/8/25, included a care of plan for psoriasis (a chronic skin condition that causes red, itchy, scaly patches).
Review of dermatologist consultation report dated 12/10/25, indicated that Resident R13's psoriasis is uncontrolled by topical medications, and he required a systemic medication.
The consultation report further stated, Blood work was also ordered today, he needs the labs completed prior to starting the medication.
Review of Resident R13's progress notes failed to reveal any notes dated 12/10/25, through 12/14/25.
Review of a progress note dated 12/15/25, at 2:00 p.m. indicated, Resident asking staff about bloodwork, culture of right knee, and x-ray of right knee.
This nurse asks RN (registered nurse) to see if any such orders exist and RN couldn't locate any orders. RN supervisor went and spoke with resident regarding this situation.
Review of a progress note dated 12/16/25, at 2:42 p.m. indicated staff from the dermatology office called and stated that labs were ordered and must be completed prior to starting the medication.
Review of a physician's order dated 12/16/25, indicated the laboratory orders of :Hepatic function 2000 panel (liver function panel)Hepatitis B virus surface Ab (tests immunity to Hepatitis B virus)Hepatitis C (tests immunity to Hepatitis C virus)Mycobacterium tuberculosis tuberculin stimulated gamma interferon (test used to detect TB infection).
The order was active for three days (12/18/25 12/21/25).
Review of a progress note dated 12/25/25, at 1:50 p.m. indicated, Lab work drawn on 12/18/25.
Further review of laboratory results and order confirmed that the lab work completed on 12/18/25, revealed that the blood tests were drawn related to an unrelated laboratory order.
Review of the clinical record failed to reveal documentation that the blood tests were completed.
During an interview on 12/22/25, at 12:59 p.m. the Nursing Home Administrator confirmed that the blood tests were not completed.
During an interview on 12/23/25, at 1:34 p.m.
Resident R13 confirmed that that the blood tests were not yet completed.
During a review on 12/29/25, at 2:00 p.m.
Resident R13 confirmed that that the blood tests were not yet completed.
During an electronic interview on 12/29/25, at 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to obtain laboratory services as ordered for one of three residents. 28 Pa.
Code: 201.14(a)(c) Responsibility of licensee.28 Pa.
Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Facility ID: