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

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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 May 6, 2025, 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 and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:
Based 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).

Findings include:

Review of facility policy "Activities of Daily Living (ADL), Supporting reviewed 1/22/25, indicated resident will be provided with care, treatment and services as appropriate to maintain activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene/bathing.

Review of the clinical record indicated Resident R1 was admitted to the facility on 4/10/25, with diagnoses that included diabetes, right ankle foot ulcer, and morbid obesity.

Review of the Minimum Data Set (MDS - comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 4/14/25, indicated the diagnoses remain current and Resident R1 requires extensive assistance of two people for ADLs.

A review of the facility shower schedules indicated Resident R1 gets showers on Wednesdays and Saturdays. A review of the ADL-Shower Task documentation dated April 2025 indicated a shower was not given or offered on 4/19, 4/23, and 4/30/25 as scheduled for Resident R1.

Review of the clinical record indicated Resident R2 was admitted to the facility on 6/18/21, with diagnoses that included dementia and Down's Syndrome (a genetic condition where a person is born with an extra copy of chromosome 21 that can affect how the brain and body develop).

Review of the MDS dated 1/31/25, indicated the diagnoses remain current and Resident R2 requires extensive assistance of one person for ADLs.

A review of the facility shower schedules indicated Resident R2 gets showers on Wednesdays and Saturdays. A review of the ADL-Shower Task documentation dated April 2025 indicated a shower was not given or offered on 4/2, 4/5, 4/12, 4/16, 4/26, and 4/30/25 as scheduled for Resident R2.

Review of the clinical record indicated Resident R3 was admitted to the facility on 11/8/18, with diagnoses that included diabetes, PVD (peripheral vascular disease - a slow and progressive disorder of the blood vessels), and chronic pain.

Review of the MDS dated 4/16/25, indicated the diagnoses remain current and Resident R3 requires extensive assistance of two people for ADLs.

A review of the facility shower schedules indicated Resident R3 gets showers on Tuesdays and Fridays. A review of the ADL-Shower Task documentation dated April 2025 indicated a shower was not given or offered on 4/1, 4/4, 4/8, 4/18, and 4/25/25 as scheduled for Resident R3.

During an interview on 5/6/25, at 4:00 p.m. The Nursing Home Administrator confirmed the above findings, and the facility failed to make certain that showers and baths were provided or offered as scheduled for Residents R1, R2, and R3.

28 Pa. Code: 211.12(1) Nursing services.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12 (2)(5) Nursing services.

Plan of Correction - To be completed: 05/31/2025

Resident 1,2, and 3 shower schedule reviewed to ensure all resident shower days are accounted for. Resident 1,2, and 3 were immediately offered shower.

DON/Designee will conduct house audit of all resident shower days to review current schedule and documentation of showers given on scheduled days

To prevent this from occurring again the nursing staff will be re-educated on providing resident shower/bath according to the shower schedule by DON or designee.

DON or designee will audit shower schedule 3x weekly x 4 weeks then monthly x 2 months. Results of the audits will be submitted to the Quality Assurance Committee for further recommendations and follow-up.

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