Wecare at Monroeville Rehabilitation and NSG CTR

In the surveyor’s words

From the most serious findings on record at Wecare at Monroeville Rehabilitation and NSG CTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 21, 2026

  Based on observations, resident interviews, staff interviews, review of facility policies and Safety Data Sheets (standardized document that provides detailed information about the hazards, safe handling, storage, and emergency measures for chemical substances or mixtures), and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to have working laundry equipment to ensure clean and sanitized linens/laundry. […]

• Immediate jeopardy, isolatedF689Apr 16, 2026

  Based on observations, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units observed (First and Second Nursing Units). This failure resulted in a harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 26 of 41 residents (Residents R1,R8,R14,R15,R18,R19, R22,R24,R25,R32,R38,R40,R44,R48,R51,R52,R61,R67,R69,R70 R72,R73,R74 R77,R78 ) who were identified as having the physical ability to access hot water outlets in the sinks and/or shower rooms throughout the entire facility.Findings… […]

• Immediate jeopardy, isolatedF689Mar 31, 2025

  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 two residents (Resident R1). This failure created an immediate jeopardy situation for 19 of 91 residents. This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. […]

• Actual harm, isolatedF600May 21, 2026

  Based on review of the facility policies, facility submitted data, clinical record and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from verbal and physical abuse which resulted in the harm of Resident R1 to be fearful of staff for one four residents reviewed (Resident R1).Finding include:Review of the facility policy Abuse and Neglect-Clinical Protocol dated 4/1/26, indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. […]

• Actual harm, isolatedF600Mar 31, 2025

  Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of an elopement for one of two residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Abuse and Neglect - Clinical Protocol dated 1/22/25, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. […]