Health Center At The Hill At Whitemarsh, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette Hill, Pennsylvania.
- Location
- 4000 Fox Hound Drive, Lafayette Hill, Pennsylvania 19444
- CMS Provider Number
- 396113
- Inspections on file
- 15
- Latest survey
- December 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Health Center At The Hill At Whitemarsh, The during CMS and state inspections, most recent first.
The facility did not comply with hot water temperature regulations, as water temperatures exceeded 110°F in two resident rooms and a spa on the 3rd floor. Observations and measurements showed temperatures of 116°F, 113°F, and 111.9°F. Interviews confirmed the absence of a mixing valve to regulate temperatures, with the shower room connected to a 120°F line.
The facility failed to maintain a clear means of egress as required by NFPA 101. Items were observed blocking the 2 North Kitchen fire exit to the café, which was confirmed by the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of hazardous areas, affecting two levels. On the third floor, an unsealed penetration was found in a storage room, and a transformer room door lacked a self-closer. On the second floor, combustible boxes were atop an electrical transformer in the kitchen dry storage. These issues were confirmed with the Administrator and Maintenance Director.
The facility was found to have incomplete automatic sprinkler protection, specifically in the South JCI room on the second floor, as observed during a survey. This deficiency was confirmed in an interview with the Administrator and Maintenance Director.
A surveyor identified an unsealed penetration around a plastic pipe on the second floor, South, above smoke doors by reception, compromising the smoke barrier wall's integrity. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to protect electrical wiring, as a duplex switch in the 2-South electrical transformer room was missing its protective cover, exposing the inner wiring. This was confirmed during an exit interview with the Administrator and Maintenance Director.
Non-compliance with Hot Water Temperature Regulations
Penalty
Summary
The facility failed to maintain water temperatures below the required 110 degrees Fahrenheit in two resident rooms and one resident spa on the 3rd floor. Observations on December 23, 2024, revealed that the water in the resident spa located inside rooms 312 and 313 was very warm to the touch. Water temperatures were measured by a maintenance employee and found to be 116 degrees Fahrenheit in the spa shower handheld sprayer, 113 degrees Fahrenheit in room 312's sink, and 111.9 degrees Fahrenheit in room 313's sink. Interviews with the maintenance employee and the administrator confirmed that the water temperatures should be below 110 degrees Fahrenheit and that the water supply to rooms 312 and 313 did not have a mixing valve to regulate the temperature, with the shower room connected to a 120-degree Fahrenheit line.
Plan Of Correction
On occupancy inspection of an unoccupied resident unit, two bathrooms, water ran for a few minutes, and temperatures obtained. Maintenance immediately adjusted water control. Temperatures checked in every resident room on 3 North, and spa, and all below 110 degrees. No residents were affected as this was an unoccupied unit. All areas where residents occupy have been checked per policy, and below 110 degrees Fahrenheit. Completed 12/23/24. Maintenance will increase water temp checks to the 3 North unit to two random rooms, and spa daily times 2 weeks, then random audits of two rooms on 3 North daily x 2 weeks. Will also add additional water temp checks to include the second, and third floor south daily x 2 weeks. Results will be reviewed by the NHA, director of facilities and reviewed at QAPI. Digital thermometers are installed on all new showers. Nursing will continue to follow policy to ensure the temperature remains below 110 degrees Fahrenheit prior to, and during shower. Start Date 12/27/2024. Maintenance, and nursing will be re-educated on water temp policy. Audits will be completed and reviewed. All new showers have a digital thermometer, so shower temperature is evaluated throughout shower. All new construction rooms will have water temp checked daily x 5 days prior to occupancy inspection. Policies will remain in place. Audits will be completed by maintenance, and reviewed by NHA, and director of facilities. Audits and results will be brought to QAPI for review, and determination.
Obstruction of Fire Exit in Kitchen Area
Penalty
Summary
The facility failed to maintain the means of egress free of impediments, which is a requirement under NFPA 101. During an observation on December 17, 2024, at 12:20 p.m., it was noted that items were stored directly in front of the 2 North Kitchen fire exit leading to the café. This obstruction was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:00 p.m., indicating a failure to comply with the necessary safety standards for emergency egress.
Plan Of Correction
Egress should be free of impediments. Items stored directly in front of the 2 North kitchen fire exit have been removed. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. Staff education completed on 12-30-2024. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance and egress is free from any obstruction.
Fire Resistance Deficiencies in Hazardous Areas
Penalty
Summary
The facility failed to maintain the fire resistance rating of hazardous areas in sprinklered locations, affecting two of four levels. On the third floor, an unsealed penetration around a copper pipe was observed in the resident storage room D3091, and the electrical transformer room door lacked a self-closer. Additionally, on the second floor, combustible boxes were found laying atop an electrical transformer in the kitchen dry storage area. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility should maintain the fire resistance rating of hazardous areas in sprinklered locations in all levels of facility. Per fire safety guidelines, fire caulk: 3M Fire Barrier Sealant CP 25WB+ was installed on the third-floor South resident storage room D3091 for unsealed penetration around copper pipe. The second-floor electrical transformer room door self-closer has been installed. The combustible boxes laying on top of electrical transformer in the second-floor kitchen dry storage have been removed. Staff education has been provided to ensure compliance. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. Staff education completed on 12-30-2024. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance.
Incomplete Sprinkler Coverage in Facility
Penalty
Summary
The facility failed to maintain complete automatic sprinkler protection, which is a requirement under NFPA 101 for nursing homes and hospitals. During an observation on December 17, 2024, at 12:15 p.m., it was noted that the South JCI room on the second floor lacked sprinkler protection. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
The facility will maintain automatic sprinkler protection in all levels of care. The second floor JCI room sprinkler protection has been installed. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. The Facilities Director or designee will bring such audits to the QA meeting monthly for 3 months in order for the QA team to verify compliance.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on December 17, 2024, at 12:20 p.m., a surveyor identified an unsealed penetration around a plastic pipe located on the second floor, South, above the smoke doors by reception. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
The facility will maintain smoke barrier walls of unsealed penetration. Per fire safety guidelines, fire caulk: 3M Fire Barrier Sealant CP 25WB+ was installed on the second-floor South penetration around the plastic pipe above the smoke doors by the reception area. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance.
Exposed Electrical Wiring in Transformer Room
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, as observed on December 17, 2024. During an inspection at 12:15 p.m., it was noted that a duplex switch in the 2-South electrical transformer room was missing its protective cover, leaving the inner wiring exposed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 1:00 p.m. on the same day.
Plan Of Correction
The facility will maintain protection of electrical wiring at all levels of care. The duplex switch cover in the 2-South electrical transformer room has been installed. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. The Facilities Director or designee will bring such audits to the QA meeting monthly x3 in order for the QA team to verify compliance.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
