F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical record review and staff and resident interviews, it was determined that the facility failed to
provide prescribed treatment and services related to the care of wounds for two of five residents (Resident
R4 and R5).Findings include: Review of the PICO 14 Single Use Negative Pressure Wound Therapy
(NPWT) System (device used for wound healing) directions for use indicated that the portable pump is
connected to the absorbent adhesive dressing. The dressings have a wear time of up to seven days
depending on the amount of fluid from the wound, and the pump has a battery life of 14 days. Review of
Resident R4's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum
Data Set (MDS - periodic assessment of resident care needs) dated 2/3/26, included diagnoses of heart
failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a
metabolic disorder in which the body has high sugar levels for prolonged periods of time) with the presence
of a foot ulcer. Review of hospital documentation dated 1/29/26, indicated Resident R4 had a diabetic foot
ulcer that developed osteomyelitis (inflammation of bone or bone marrow, usually due to infection), had
debridement of the wound, implementation of antibiotic beads, and was ordered a wound vac
(vacuum-assisted closure, a portable, battery-powered medical device used for negative pressure wound
therapy (NPWT) to accelerate healing in acute, chronic, or severe wounds). Review of Resident R4's
physician's orders indicated that Resident R4 did not have an active order for a wound vac until 2/13/26.
Review of Resident R4's plan of care for diabetic ulcers initiated 2/1/26, failed to include information
regarding the need for a wound vac. Review of Resident R4's progress notes revealed:-2/2/26: Physician,
Assessment and Plan: L foot w/ implantation of antibiotic beads and wound VAC; F/U with Podiatry as
directed.-2/2/26: Wound Nurse Practitioner, left midfoot diabetic foot ulcer (that had the antibiotic
beadsplaced) (per hospital record should have a wound vac placed?). Gain Clarity if patient should have a
wound vac.-2/2/26: Nurse Practitioner, Assessment and Plan: L foot w/ implantation of antibiotic beads and
wound VAC; F/U with Podiatry as directed.-2/9/26: Wound Nurse Practitioner, There was question if left foot
should have vac in place per their recommendations. Facility to clarify. ASSESSMENT/PLAN: Please clarify
if Podiatry would like wound vac to left foot.-2/16/26: Physician's Assistant, Patient questioning wound VAC
delivery.-2/16/26: Wound Nurse Practitioner, Patient seen by podiatry 2/9 still recommend wound vac to left
foot, staff continues to work on obtaining. Podiatry would like wound vac to left foot- continue to obtain.
Review of facility provided electronic documentation revealed:-Previous sister facility on 1/23/26, at 4:26
p.m. Wound vac arrived and is malfunctioning. We called the customer service number. They said to order
another one.-Business Office Manager (BOM) on 1/30/26, at 1:32 p.m. (Registered Nurse Employee E1)
has the wound vac, she will reach out to you to troubleshoot.-RN Employee E1 on 1/30/26, at 1:21 p.m. The
patient was supposed to have an appointment with his podiatry today, but it had to be rescheduled due to
transportation issues.-Regional Director on 1/30/26, at 1:23 p.m. Where is the wound vac,
Residents Affected - Some
(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 8
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
02/27/2026
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
I will get a label so we can return the wound vac.-Regional Director on 1/30/26, at 1:32 p.m. RN Employee
E1 has the wound vac, she will reach out to you.-Regional Director on 1/30/26, at 2:08 p.m. There were 2 at
that facility, one was working and one needed service.-Regional Director on 2/2/26, at 1:11 p.m. Please
update me on the status of our resident that was admitted to the facility that was supposed to get the
wound vac.-Regional Director on 2/2/26, at 1:33 p.m. Please send a return label to (facility) to return
(Resident R4's) wound vac.-BOM on 2/3/26, at 2:42 p.m. When did he start/stop the pump at (facility)? No
one put it in the system.-Regional Director on 2/3/26, at 2:47 p.m. They never started it at (facility).-Regional
Director on 2/4/26, at 6:58 a.m. Please print this label and place the wound vac in the box and return. There
should be a plastic black box, a fabric holder for the wound vac itself. If someone can confirm when the
building has left, that would be appreciated.-Regional Director on 2/12/26, at 5:37 p.m. The wound vac air
tag is still in (facility) which means the pump is still there. We need to find the pump. I sent the sticker to
send back. Was told it went back.-Regional Director on 2/13/26, at 6:15 p.m. The wound vac was located.
There were supplies delivered for that resident on January 23 of 2026. I did ask that we try to wound vac on
the resident if we can locate those supplies. Please provide an update. We also have another one coming
your way on Monday thank you. Review of a grievance submitted to the facility by Resident R4 on 2/18/26,
indicated:Summary of Complaint: Resident R4 had, No wound vac since admission on [DATE].Steps taken
to investigate: Upon arrival supplies for the wound vac were in house. The wound vac that was delivered
wasn't properly functioning. Svc call placed to company to troubleshoot. Determined that wound vac would
need to be replaced. Order changed to wet/dry dressing throughout his stay.Summary of Findings: No
wound vac present but orders changed and wound care followed.Corrective action: Communicated updates
to the residents re: wound vac status. Kept him informed about the progress of his wounds. Reviewed the
wound from (wound care provider). Verbalized that he was pleased with the progress of his wound healing.
During an interview on 2/24/26, at 12:19 p.m. Resident R4 confirmed that he never received a wound vac
during his stay at the facility, stated that he was unhappy with his wound care and never would have stated
that he was pleased with the progress of his wound healing. When asked if the facility kept him informed
about the progress of his wounds, Resident R4 stated That is a crock of shit and stated while his wound did
not deteriorate further, there was negligible improvement either. Resident R4 stated that he did not always
receive his wound care as scheduled and many times had to request to have his scheduled dressing
changes completed. Review of Resident R4's Treatment Administration Record (TAR) from 2/1/26, through
2/17/26, indicated the following orders:Wet to dry (in place of wound vac) care had no documentation on
2/1/26 night shift, 2/8/26 evening shift, 2/10/26 day shift, 2/14/26 evening shift, 2/15/26 day shift, 2/16/26
evening shift, 2/17/26 evening shift.Petrolatum gauze to right plantar foot had no documentation on 2/10/26,
2/15/26.Left mid foot wound care had no documentation on 2/10/26, 2/15/26.Left posterior thigh pressure
wound care had no documentation on 2/10/26, 2/15/26.Right mid foot wound care had no documentation
on 2/10/26, 2/15/26.Right shin wound care had no documentation on 2/10/26, 2/15/26.Xeroform to right
medial lower leg wound care had no documentation on 2/10/26, 2/15/26. Review of Resident R5's
admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE],
included diagnoses of bacteremia (presence of bacteria in the bloodstream), high blood pressure, and
history of a stroke. Review of a physician order dated 2/1/26, indicated PICO 14 Negative Pressure Wound
therapy dressing to Left femoral region per protocol. Monitor to ensure proper function and intact Seal.
Reinforce dressing as needed. Review of Resident R5's plan of care for actual skin impairment initiated
2/1/26, failed to include goal or interventions for the use of a PICO dressing. Review of Resident R5's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395670
If continuation sheet
Page 2 of 8
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
02/27/2026
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
hospital discharge paperwork dated 1/31/26, indicated Resident R5's PICO 14 dressing was placed on
1/26/26. Review of a progress note dated 2/1/26, at 1:28 a.m. indicated, (Negative Pressure dressing
[NAME] and Nephew (manufacturer) PICO 14 On, not to be touched). Review of a wound nurse practitioner
note dated 2/3/26, at 10:09 p.m. indicated, PICO (negative pressure system) intact to left groin. not
removed (7 day life, battery pack in place). Review of a wound nurse practitioner note dated 2/9/26, at 1:36
p.m. indicated, PICO (negative pressure system) intact to left groin. not removed (7 day life, battery pack in
place), replace at day 7 or 3/4, saturated dressing then at that time replace dressing only conserve battery
pack until battery pack turns off. Review of a wound nurse practitioner note dated 2/16/26, at 2:35 p.m.
indicated, PICO battery is dead, PICO dressing removed. Further review of Resident R4's clinical record
failed to reveal documentation that the dressing portion of Resident R4's PICO dressing was changed after
seven days (2/2/26, 2/9/26, 2/15/26) and that the battery pack was changed after 14 days (2/9/26). 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 prescribed treatment and services related to the care of
wounds for two of five residents 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code
211.12(d)(1)(2)(5) Nursing services.
Event ID:
Facility ID:
395670
If continuation sheet
Page 3 of 8
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
02/27/2026
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 intact8-12:
moderately impaired0-7: severe impairment Review of the clinical record revealed Resident R1 was
admitted to the facility on [DATE]. 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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395670
If continuation sheet
Page 4 of 8
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
02/27/2026
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
395670
If continuation sheet
Page 5 of 8
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
02/27/2026
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, resident interviews and observations, staff interviews, and it
was determined that the facility failed to provide appropriate respiratory care for two of four residents
(Resident R2 and R3). Findings include: Review of facility policy Administering Medications 1/8/26,
indicated medications are administered in a safe and timely manner, and as prescribed. The policy further
stated that the individual administering the medication records in the resident's medical record:-the date
and time the medication was administered;-the dosage;-the route of administration;-the injection site (if
applicable);-any complaints or symptoms for which the drug was administered;-any results achieved and
when those results were observed; and-the signature and title of the person administering the drug. 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 intact8-12: moderately impaired0-7:
severe impairment Review of the clinical record indicated Resident R2 was admitted to the facility on
[DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated
1/23/26, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often
faster heartbeat) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders
characterized by increasing breathlessness). MDS Section C: Cognitive Patterns indicated Resident R2 had
a BIMS score of 15. Review of Resident R3's plan of care for shortness of breath related to Flu A (influenza
type A) and COPD initiated 1/20/26, failed to include the use of respiratory medications or nebulizer
treatments. Review of a physician's active orders dated 1/20/26, Resident R2 is to receive a Breo Ellipta (a
once-daily, dry-powder maintenance inhaler used to control symptoms of COPD). The order was further
documented that a therapeutic interchange was completed, and Resident R2 was to receive
Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution, Inhale the contents of 1 ampule via nebulizer every 8
hours. Review of Resident R2's Medication Administration Record (MAR) for the use of the Breo Ellipta
from 2/1/26, through 2/24/26, indicated the following:2/01/26: Received2/02/26: Held by nurse2/03/26:
Received2/04/26: Received2/05/26: Received2/06/26: Received2/07/26: Received2/08/26:
Received2/09/26: Held by nurse2/10/26: Received2/11/26: Held by nurse2/12/26: Received2/13/26: Held by
nurse2/14/26: Received2/15/26: Received2/16/26: Received2/17/26: Held by nurse2/18/26: Held by
nurse2/19/26: Received2/20/26: Received2/21/26: Received2/22/26: Undocumented2/23/26:
Received2/24/26: Received Further review of Resident R2's MAR revealed no information and timing were
available to document the use of Ipratropium-Albuterol three times daily, in place of the once daily Breo
Ellipta. Resident R3 was unavailable for interview at this time. During an interview 2/24/26, at approximately
1:45 p.m. Resident R2 confirmed that he has not been receiving his Breo Ellipta inhaler. Review of the
clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS needs
dated 2/3/26, included diagnoses of coronary artery disease (damage or disease in the heart's major blood
vessels) and COPD. MDS Section C: Cognitive Patterns indicated Resident R3 had a BIMS score of 14.
Review of Resident R3's plan of care for shortness of breath initiated 2/1/26, failed to include the use of
respiratory medications or nebulizer treatments. Review of a physician's active orders dated 1/30/26,
Resident R3 is to receive a Trelegy Ellipta (a once-daily, dry-powder maintenance inhaler used to treat
COPD). Review of a physician's active orders dated 1/30/26, Resident R3 is to receive
Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG/ACT, one inhalation every six hours as
needed for COPD. The order was documented that supplied by the pharmacy was Ipratropium-Albuterol
0.5-2.5 (3) MG/3ML Solution, Inhale the
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395670
If continuation sheet
Page 6 of 8
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
02/27/2026
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
contents of 1 ampule via nebulizer every 6 hours as needed for COPD, Review of Resident R3's Medication
Administration Record (MAR) for the use of the Trelegy Ellipta from 2/1/26, through 2/24/26, indicated the
following:2/01/26: Received2/02/26: Received2/03/26: Received2/04/26: Held by nurse2/05/26:
Received2/06/26: Received2/07/26: Received2/08/26: Received2/09/26: Held by nurse2/10/26:
Received2/11/26: Held by nurse2/12/26: Received2/13/26: Held by nurse2/14/26: Received2/15/26:
Received2/16/26: Received2/17/26: Held by nurse2/18/26: Held by nurse2/19/26: Received2/20/26:
Received2/21/26: Received2/22/26: Undocumented2/23/26: Received2/24/26: Received During an
observation on 2/24/26, at approximately 1:50 p.m. of the 100-unit hall medication cart, Resident R2's Breo
Ellipta inhaler and Resident R3's Trelegy Ellipta inhaler were not present in the medication cart. Both
resident had pharmacy supplied boxes of Ipratropium-Albuterol 0.5-2.5 ampules present, with the notation
on the pharmacy label as therapeutic interchange. Both boxes appeared unused, and when opened had
the full supply of ampules present. During an interview on 2/24/26, at approximately 1:52 p.m. Licensed
Practical Nurse (LPN) Employee E1 confirmed that Resident R2 and R3's inhalers were not present in the
medication cart and confirmed that no Ipratropium-Albuterol ampules had been removed from the boxes in
the medication cart. When asked why both Resident R2 and Resident R3 had documentation in their MARs
that they received their inhalers during the 9:00 a.m. med pass earlier in the day, LPN Employee E1 was
unable to provide an answer. During an observation on 2/24/26, at approximately 2:10 p.m., upon entering
the shared room of Resident R2 and R3, both residents were observed to be having a nebulizer treatment.
Interviews at this time confirmed that neither resident had ever received prior nebulizer treatments while in
the facility, and Resident R3 confirmed that he has not been receiving his Trelegy Ellipta inhaler. During an
interview on 2/24/26, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed
that the facility failed to provide appropriate respiratory care for two of four residents. 28 Pa. Code:
201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
Event ID:
Facility ID:
395670
If continuation sheet
Page 7 of 8
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
02/27/2026
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
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 shouldnot sound2. Apply pressure to the door release for the
pre-determined nuisance period setting (normally1-3 seconds)3 Door should go into irreversible unlocking
sequenceDoor alarm will soundDoor will automatically open within (15-30 seconds)4 Close door and reset
the alarm5 Ensure signs are placed on doors adjacent to the release device that read 'Push until
alarmsounds. Door can be opened in 15 seconds.6 Confirm that security panels at Nurse Station activate
when door is opened and that itproperly 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.
Event ID:
Facility ID:
395670
If continuation sheet
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