Pennsylvania Department of Health
WECARE AT MONROEVILLE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WECARE AT MONROEVILLE REHABILITATION AND NURSING CENTER
Inspection Results For:

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WECARE AT MONROEVILLE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to four complaints, completed on February 24, 2026, it was determined that WeCare at Monroeville Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:
Based 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.

Findings include:

Review of the facility "Maintenance Manager" job description indicated the Maintenance Manager "Maintains competency &; is tested to be competent in:
Machine Maintenance requirementsFire Prevention &; SafetyInfection Control/OSHA &; CDCFacility Maintenance requirements
Review of the facility alarm testing instructions stated:
Check delayed egress operation (if applicable)
1. Push door release hard for a fraction of a second - door should not open and alarm should
not sound
2. Apply pressure to the door release for the pre-determined nuisance period setting (normally
1-3 seconds)
3 Door should go into irreversible unlocking sequence
Door alarm will soundDoor will automatically open within (15-30 seconds)4 Close door and reset the alarm
5 Ensure signs are placed on doors adjacent to the release device that read 'Push until alarm
sounds. Door can be opened in 15 seconds."
6 Confirm that security panels at Nurse Station activate when door is opened and that it
properly indicates the location of the door released.
7 Door keypad battery shall be replaced annually, if applicable.

During an interview on 2/23/26, at approximately 11:00 a.m. the Maintenance Director and surveyor attempted to check door alarm functionality. Maintenance Director was unaware how to deactivate the alarm. Nursing staff were required to respond to the alarming door to silence the alarm and reactivate the door locking mechanism. When asked how he ensures the door alarms are functional, Maintenance Director stated he checks the door by attempting to open it to ensure that it is locked. At this time, the Maintenance Director confirmed that action only ensures the door is locked, but does not verify functionality of the alarm.

During an interview on 9/19/25, at 1:01 p.m. Nursing Home Administrator confirmed that the facility failed to make certain door alarm systems were regularly tested for functionality.

28 Pa. Code 201.14 (a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3) Management.

Plan of Correction - To be completed: 04/01/2026

Regional Maintenance checked the doors to ensure functionality
Regional Maintenance will educate the Maintenance Director and Maintenance Assistant on the steps to properly check the door alarm functionality
NHA or designee will audit to ensure the maintenance director properly checks the door alarm functionality weekly for 2 weeks. Door audits will continue as a weekly PM conducted by Maintenance
Audits will be reviewed at QAPI

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 04/01/2026

The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements.

R4 discharged on 2/18/26
R5 RTH on 2/17/26
DON conducted a whole house audit of wound orders to ensure accuracy and completion
DON or designee to educate licensed nurses on wound treatment and wound vac care.
DON or designee will audit 5 resident wound orders including wound vac if applicable to ensure they are being properly followed weekly for 2 weeks
Audits will be reviewed at QAPI

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 04/01/2026

R3 discharged 2/27/26
R2 Breo Ellipta is ordered and present in the medication cart
DON completed a whole house audit of residents with Inhaler orders to ensure the medication is present and administered
DON or designee will educate licensed nurses on the administering medications, pharmacy therapeutic interchange, and MAR/TAR documentation.
DON or designee will audit 5 residents with Inhaler orders to ensure medication is present and administered weekly for 2 weeks
Audits will be reviewed at QAPI

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations: Based 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. Findings include: Review of the facility policy "Wandering and Elopements" dated 1/8/26, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining he lest restrictive environment for residents. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ("BIMS"), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed Resident R1 was admitted to the facility on 1/10/25. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/15/25, included diagnoses of atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), age-related debility, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R1 had a BIMS score of "8." Review of an "Elopement Risk Evaluation" completed on 11/22/25, at 5:47 p.m. indicated Resident R1 was at risk for elopement. Review of Resident R1's plan of care for "At risk for elopement" initiated 1/11/25, indicated, "Will remain safe within facility unless accompanied by staff or other authorized person." Review of a physician's order dated 7/9/25, indicated for staff to monitor Resident R1's wandering behavior. Review of facility submitted information submitted 2/12/26, indicated that on 2/10/26, at 5:30 p.m. "[Resident R1] was identified by staff to have wandered out of the facility. The resident was immediately recovered by staff and redirected back into the facility." "The resident was last seen at 1718 (5:18 p.m.) by a CNA (nurse aide). The resident was brought back into the building at 1720 by an LPN (licensed practical nurse) who sighted the resident outside of the building. The resident was wearing a long sleeve shirt with pants and a pair of loafer shoes. The temperature outside was 50 degrees Fahrenheit on that day." Review of a progress note dated 2/10/26, at 8:12 p.m. indicated, "Resident was discovered to have walked outside of the building via the back door on the 200s side. The door opened easily and low alarm rang, but not the loud alarm it remained silent. Review of an employee statement written by Nurse Aide (NA)Employee E1, dated 3/17/24, indicated, "On 3/11 shift, I was walking out of a resident's room after changing them, when I seen a guy walk out of another residents room who I never recognized being down that hallway to begin with so I was under the assumption that it was a residents family member. He ended up walking to the Exit doors trying to get out, not recognizing the alarm on his ankle nor did any alarms go off as he exited the building. About ten minutes after him leaving the building is when the alarms on side 2 start going off as he came back into the facility." On 2/10/26, the facility initiated a plan of correction that included: -Resident assessment to ensure no injuries. -Notification of resident representative and medical provider. -Checks every 15 minutes on Resident R1. -Immediate head count of all residents in the facility. -Immediate functionality checks on exit doors and alarms. -A whole house audit of all residents with updated elopement assessments completed for each resident. -Facility-wide reeducation was completed with all staff on policies and procedures related to elopement. -Daily head counts completed by the Director of Nursing or Designee to ensure residents are accounted for. -Door alarm functionality audits completed twice per shift. -Daily door alarm checks for all facility exit doors. -Audits to be forward to the monthly Quality Assurance and Performance Improvement Committee for review. The facility was back in compliance on that date. Interviews with five licensed nursing staff on 2/24/26, confirmed they received education on elopement prevention and procedures if an elopement occurs. Nurses were able to demonstrate alarm door functionality. During an interview on 3/29/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of seven residents, that was determined to be past noncompliance. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 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.

Plan of Correction - To be completed: 03/08/2026

Past noncompliance: no plan of correction required.

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