Inspection visit

Health inspectionJune 13, 2025

WECARE AT MONROEVILLE REHABILITATION AND NSG CTRCMS #3956702 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner for one of four nursing medication carts (100 Hall) and failed to label multi-dose vials and check expiration dates for two of four nursing medication carts (100 and 200 Hall). Finding include: Review of facility policy Administering Medications dated [DATE], indicated during administration of medications, the medication cart is kept closed and locked when out of site of the medication nurse or aide. The policy also states the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. During an observation and staff interview on [DATE] at approximately 8:43 a.m. the Side 1-Front 100 Hallway medication cart was left open and computer screen visible with patient information with no nurse or aide at cart. During an observation of the Side 1-Front 100 Hallway cart and the Back Hallway 200 side cart indicated that multi-dose bottles of medication were not labeled with open date and some of those same bottles had expired. During an observation of the Medication Room and Central Supply Room multiple expired supplies were discovered. -100 Cart: Vitamin A, Expired 5/2025, not labeled when opened. -100 Cart: Dairy Aid, Expired 3/2024, not labeled when opened. -200 Cart: Bisacodyl Suppository, Expired 1/2025, 2 boxes, not labeled when opened. -200 Cart: Omeprazole, Unable to read expiration date and not labeled when opened. -200 Cart: Fish Oil 500mg, Expired 4/2025 and was labeled opened [DATE]. -200 Cart: Saccharomyces boulardii probiotic, Expired 11/2024, dated with an opened date of [DATE]. (continued on next page) 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 (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 395670 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wecare at Monroeville Rehabilitation and Nsg Ctr 4142 Monroeville Blvd Monroeville, PA 15146 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 -200 Cart: Zinc 50mg, Expired 3/2025, not labeled when opened. Level of Harm - Minimal harm or potential for actual harm -Central Supply: Purple top blood collection tubes- Expired [DATE] -Central Supply: Grey top blood collection tubes-Expired [DATE] Residents Affected - Some -Central Supply: Gastroccult test slides- Expired [DATE] -Central Supply: Next Temp Disposable Thermometers- Expired 5-12-25 -Central Supply: EMS IV Start kit- Expired [DATE] -Central Supply: Dairy Aid- Expired 3/2024 (3 bottles) -Central Supply: Preservision-Expired 5/2025 -Central Supply: Geri-tussin-Expired 5/2025 (3 bottles) -Central Supply-IV Administration set- Expired 5-16-25 Interview on [DATE], at 8:53 a.m., Licensed Practical Nurse (LPN) Employee E2 verified the findings noted above. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services 28 Pa. Code: 211.10(a)(c)(d) Resident Care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395670 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wecare at Monroeville Rehabilitation and Nsg Ctr 4142 Monroeville Blvd Monroeville, PA 15146 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to complete education regarding, Coronavirus Disease (COVID) vaccination for three of five residents (R9, R18, R50), influenza vaccination education for two of five residents (R32, R50) and pneumococcal vaccination education for five of five residents (R9, R18, R32, R36, R50). Residents Affected - Some Finding include: Review of the facility policy Coronavirus Disease (COVID-19)-Vaccination of Residents policy dated 6/1/25, indicated before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Review of the facility policy Influenza Vaccine dated 6/1/25, indicated the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record. Review of the facility policy Pneumococcal Vaccine dated 6/1/25, indicated before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the resident's medical record. Review of the facility's policy Vaccination of Residents dated 6/1/25, all residents prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. Provisions of such education shall be documented in the residents medical record. Review of the admission record indicated Resident R9 was admitted to the facility on [DATE], and received the COVID-19 vaccine on 12/2/21, Pneumococcal vaccine received on 11/3/22, with education documented as not completed. Review of the admission record indicated Resident R18 was admitted to the facility on [DATE], and received the COVID-19 vaccine on 7/6/22, Pneumococcal vaccine was received on 10/26/23, with education documented as not completed. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE], and received the Pneumococcal vaccine on 6/20/24, the Influenza vaccine was refused, with education documented as not completed. Review of the admission record indicated Resident R36 was admitted to the facility on [DATE], and received the Pneumococcal vaccine on 6/20/24, with education documented as not completed. Review of the admission record indicated Resident R50 was admitted to the facility on [DATE], and received the COVID-19 vaccine on 10/29/21, Pneumococcal vaccine on 10/26/23, with education documented as not completed. During an interview on 6/13/25, at 1:15 p.m. Nursing Home Administrator (NHA) and Regional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395670 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wecare at Monroeville Rehabilitation and Nsg Ctr 4142 Monroeville Blvd Monroeville, PA 15146 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Administrator confirmed that the facility failed to document or provide education for COVID-19 for three of five residents (Resident R9, R18, R50) Influenza for two of five residents (Resident R32, R50), or Pneumococcal vaccines for five of five residents (Resident R9, R18, R32, R36, R50). 28 Pa. code: 211.5(f) Clinical Records Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395670 If continuation sheet Page 4 of 4

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Citations

2 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.

FAQ · About this visit

Common questions about this visit

What happened during the June 13, 2025 survey of WECARE AT MONROEVILLE REHABILITATION AND NSG CTR?

This was a inspection survey of WECARE AT MONROEVILLE REHABILITATION AND NSG CTR on June 13, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WECARE AT MONROEVILLE REHABILITATION AND NSG CTR on June 13, 2025?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 13, 2025