Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quality Life Services - Westmont during CMS and state inspections, most recent first.
Failure to Provide Written Transfer Notifications The facility did not document written notice to the resident or RP explaining hospital transfers for multiple residents. The affected residents had varied conditions including cognitive impairment, Parkinson’s disease, CHF, CKD, cellulitis, pain, lethargy, weakness, chest pain, SOB, UTI, dehydration, and respiratory decline, and were sent to the hospital for evaluation or treatment without evidence that the required written transfer notifications were provided.
Failure to follow carvedilol orders and notify physician for elevated BP. A resident with HF and HTN had an order for carvedilol BID with parameters to hold for low SBP or HR and to call the MD for SBP over 170 mmHg. MAR review showed multiple elevated SBP readings without evidence of MD notification, and the med was also given when the resident’s HR was below 60 bpm, despite the hold parameter.
Improper Labeling and Storage of Medications and Expired Supplies: An LPN and the NHA confirmed that one bottle of eye drops and two open vials of tuber sol were not labeled with the date opened, and expired medical supplies were found in a medication room, including Huber needles, IV starter kits, and IV catheters. The facility policy required opened multi-dose meds to be dated and discarded within 28 days unless the manufacturer specified otherwise.
An LPN failed to follow infection control practices during medication administration for a resident. She handled stock Fish Oil and Senna/Docusate capsules with bare hands, picked up a pill from the medication cart with her bare hands, and placed the medications into the cup before giving them to the resident. The LPN and DON both confirmed staff were not to touch residents' medications with bare hands.
The facility failed to adhere to physician's orders for medication administration for two residents, leading to inappropriate administration of Metoprolol, Amlodipine, Atenolol, and Hydralazine despite contraindicated blood pressure readings. Additionally, a resident received health shakes and fortified foods without a physician's order following hospital readmission. These actions were confirmed by facility staff.
A resident with diabetes did not have their insulin held as ordered by the physician when their blood sugar levels were below the specified threshold. The facility's failure to adhere to the physician's orders resulted in significant medication errors, as confirmed by the Nursing Home Administrator.
The facility failed to maintain sanitary conditions in the main kitchen, with surveyors observing dust and food debris under and behind the ice machine and stove. Items such as a clear drinking glass, a small red bowl, and a [NAME] Cup were also found misplaced. The Dietary Manager confirmed these findings.
The facility's QAPI committee failed to address repeated deficiencies, including inaccurate MDS assessments, inadequate care plans, and issues with medication accountability and food sanitation. Despite previous corrective plans, the same issues were cited again, indicating ineffective implementation.
A resident with a history of psychotic disorder and schizophrenia was verbally abused by a nurse aide, who made inappropriate comments about the resident's behavior. The incident was overheard by a registered nurse supervisor, who failed to report it immediately. The resident could not recall the incident, and other residents reported hearing a loud voice but could not confirm the content.
The facility failed to ensure timely reporting of verbal abuse allegations involving two residents. A resident with schizophrenia was allegedly verbally abused by a nurse aide, but the incident was not immediately reported by the RN supervisor. Another resident with COPD experienced a similar incident, which was delayed in reporting by a nurse aide. Both incidents violated the facility's abuse policy.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect documentation of medication administration. A resident receiving gabapentin for rheumatoid arthritis was not recorded as receiving anticonvulsant medication, while another on Seroquel was not noted as receiving antipsychotic medication. A third resident's gabapentin administration for polyneuropathy was also inaccurately documented. These discrepancies were confirmed by the Nursing Home Administrator.
A facility failed to create a care plan for a resident on Enhanced Barrier Precautions (EBP) due to a surgically implanted drain. Despite physician's orders and EBP signage, there was no documented care plan addressing the resident's specific needs. Staff interviews confirmed the requirement for gown use, but the Nursing Home Administrator acknowledged the lack of a care plan.
A facility failed to monitor a resident's weight as recommended by the dietitian, leading to a deficiency. The resident, who was moderately cognitively impaired, experienced significant weight fluctuations without timely re-weighing as per facility policy. The Director of Nursing and Nursing Home Administrator confirmed the oversight.
A facility failed to maintain accurate records for a resident's controlled medication, Clonazepam, used for anxiety. Although doses were signed out in the drug logs, there was no documentation in the MARs or nursing notes confirming administration on several occasions. The Nursing Home Administrator confirmed the absence of documentation.
A resident with an anxiety disorder was frequently administered Clonazepam without documented attempts of non-pharmacological interventions as required by their care plan. The facility failed to ensure these interventions were tried before medication, as confirmed by the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to discrepancies between the care plans and the residents' current conditions. One resident's care plan inaccurately indicated the use of oxygen and fall mat placement, another's care plan did not reflect the resolution of a pressure ulcer, and a third's care plan did not account for the removal of a PEG tube.
The facility failed to follow physician's orders for medications for three residents. One resident did not have their blood pressure monitored as required, another continued to receive a nutritional supplement after their wound had healed, and a third did not have their blood pressure and heart rate monitored as ordered. These deficiencies were confirmed by the Director of Nursing.
The facility failed to maintain accountability for controlled medications for three residents, as multiple doses of Tramadol, Lorazepam, and Oxycodone were signed out but not documented as administered in the MAR or nursing notes. This deficiency was confirmed by the Director of Nursing.
The facility failed to ensure a clean and homelike environment for a resident who was moderately cognitively impaired and used a wheelchair. Observations revealed a dried, brown/tan, removable substance on the wheelchair, and interviews confirmed the lack of a routine cleaning schedule. The DON stated that wheelchairs were power washed twice a year, but the resident's wheelchair had a removable substance that should have been cleaned.
The facility failed to verify the professional licensure of an LPN with the Pennsylvania State Board of Nursing prior to hire, as required by their abuse policy. This was confirmed by the DON during an interview.
The facility failed to develop individualized care plans for two residents. One resident, who was frequently incontinent, did not have a care plan addressing bladder incontinence. Another resident, with multiple lung-related diagnoses, did not have a care plan for long-term antibiotic therapy. The DON confirmed the absence of these care plans.
A resident at risk for falls, who was cognitively impaired and required assistance for daily care, did not have a tether alarm attached as required by the care plan. This deficiency was confirmed through staff interviews and observations.
The facility failed to obtain physician's orders for oxygen therapy for two residents. One resident with heart failure, respiratory failure, and COPD was using oxygen at 3 L/min without an order, and another resident with pulmonary fibrosis, respiratory failure, and COPD was using oxygen at 7 L/min without an order. The Director of Nursing confirmed the lack of required physician's orders.
A resident with cognitive impairment and diabetes received Novolog insulin on multiple occasions despite blood sugar levels being below the threshold specified in the physician's orders. The Director of Nursing confirmed that the parameters were not followed on 14 occasions, leading to significant medication errors.
The facility failed to discard two expired multi-dose insulin vials and did not securely store medication in the medication cart on B Hall. An LPN left Januvia tablets unsupervised on top of the cart, and the cart was observed unlocked with no staff in view. Insulin vials were not properly labeled or discarded after expiration.
The facility failed to discard an opened, expired container of Miracle Whip salad dressing found in the small kitchen refrigerator, as confirmed by the Dietary Manager.
The facility's QAPI committee failed to correct and maintain compliance with quality deficiencies identified in previous surveys, leading to repeated deficiencies in areas such as comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food procurement-storing/preparing/serving food under sanitary conditions.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to the resident and/or the resident’s representative regarding the reason for transfer to the hospital for 8 of 22 residents reviewed. The deficiency was identified through review of policies, clinical records, and staff interviews, and was confirmed by the Nursing Home Administrator. The cited issue involved the absence of documented written transfer notices for Residents 3, 4, 5, 7, 17, 18, 32, and 41. Resident 3 was cognitively impaired, required assistance with all daily care needs, and had diagnoses including RSV pneumonia. The record showed hospital transfers for DVT and later worsening respiratory conditions with RSV, but there was no documented evidence that a written transfer notice was provided to the responsible party. Resident 4 was cognitively impaired, required maximum assistance, and had chronic kidney disease; she was transferred to the hospital after being minimally responsive with a draining thigh wound and again after becoming lethargic and unable to maintain oxygen saturation, yet no written notification was documented. Resident 5 was cognitively impaired, dependent for daily care, and had arthritis and pain. He was sent to the hospital after intractable pain unrelieved by bedrest and medication, and again after crying out in pain during repositioning, with no documented written notice to the responsible party. Resident 7, who was cognitively impaired and had Parkinson’s disease, had multiple hospital transfers for change in mental status, chest pain, behavioral changes, significant pain, lethargy with right-sided weakness, and increased lethargy with marked weakness; no written transfer notices were documented. Resident 17, who was severely cognitively impaired with kidney failure and Parkinson’s disease, was transferred for dehydration; Resident 18, who was cognitively intact with heart failure and hypertension, was transferred for weakness, UTI, and ambulatory dysfunction; Resident 32, who was cognitively intact with heart failure and hypertension, was transferred for shortness of breath and chest pain; and Resident 41, who was cognitively intact with cellulitis of the right lower limb, was transferred after a hard, large, tender femoral popliteal bypass incision. For each of these residents, the record lacked documented evidence that written transfer notification was provided to the resident’s representative or responsible party.
Failure to Follow Carvedilol Orders and Notify Physician for Elevated BP
Penalty
Summary
The facility failed to ensure that medications were provided as ordered for one resident with an admission MDS dated January 22, 2026. The resident was cognitively intact, required staff assistance with daily care needs, and had diagnoses including heart failure and high blood pressure. Physician orders dated January 20, 2026 directed that carvedilol 12.5 mg be given twice daily, held if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 beats per minute, and that the physician be called if systolic blood pressure was greater than 170 mmHg. Review of the MAR for January and February 2026 showed multiple systolic blood pressure readings above 170 mmHg, including 186/73, 176/76, 176/76, 180/70, and 181/67, with no evidence that the physician was notified on those dates. The MAR also showed a blood pressure of 162/78 with a heart rate of 54 beats per minute, yet carvedilol was administered even though the order required it to be held when the heart rate was below 60. The Nursing Home Administrator confirmed that the physician should have been notified for the elevated systolic blood pressures and that the medication should have been held for the low heart rate, but it was not.
Improper Labeling and Storage of Medications and Expired Supplies
Penalty
Summary
The facility failed to label one bottle of Latanoprost Ophthalmic Solution 0.005 percent eye drops in the B medication cart with the date it was opened. The facility also failed to label two open vials of tuber sol in the medication room refrigerator with the date they were opened. The facility policy on medication labeling and storage stated that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. In addition, the facility failed to discard expired medical supplies in one medication room. Observations revealed nine Huber needles that had expired in November 2024 and August 2025, twenty-one intravenous starter kits that had expired in January 2023, February 2024, and [DATE], and four 22 gauge intravenous catheters that had expired in September 2025. An LPN confirmed that the eye drops and tuber sol were not properly labeled and that expired medical supplies should not be in the medication room. The NHA also confirmed that multi-dose medications should have been labeled with an expiration date and that expired medical supplies should not have been in the medication room.
Improper Handling of Medications During Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for one resident. During observation of medication pass, an LPN prepared medications for the resident and obtained Fish Oil and Senna/Docusate from stock medication bottles used for multiple residents. The LPN touched the capsules with her bare hands and placed them into the medication cup, then picked up a pill that had fallen on the top of the medication cart with her bare hands and placed it into the cup before administering the medications to the resident. The facility policy dated November 11, 2025 stated that medications were to be administered as prescribed in accordance with nursing principles and practice. The LPN confirmed she should not have touched the medication with her bare hands, and the DON confirmed staff were not to touch residents' medications with their bare hands.
Failure to Follow Physician's Orders for Medication and Nutrition
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not adhering to physician's orders for medication administration for two residents. Resident 24, who was cognitively impaired and required maximum assistance, was administered Metoprolol on multiple occasions despite her blood pressure readings being below the hold parameters specified by the physician's orders. This oversight was confirmed by the Nursing Home Administrator. Resident 25, who had hypertension and was understood to be able to communicate, was also administered medications contrary to physician's orders. The resident received Amlodipine and Atenolol despite having blood pressure readings below the specified hold parameters. Additionally, there was no documented evidence that the resident's heart rate was checked before administering Atenolol and Hydralazine, as required by the physician's orders. These discrepancies were confirmed by the Nursing Home Administrator. Furthermore, Resident 14, who was moderately cognitively impaired and had experienced weight loss, continued to receive health shakes and fortified foods without a physician's order following a hospital readmission. The Dietitian and Dietary Manager confirmed that these supplements were provided based on previous orders, but a new physician's order was not obtained upon the resident's readmission. This lack of adherence to obtaining necessary physician's orders contributed to the facility's failure to meet professional standards of practice.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in significant medication errors for one resident. The facility's policy required medications to be administered safely and in accordance with physician's orders. However, for Resident 32, who was alert, oriented, and diagnosed with diabetes, the facility did not adhere to the physician's orders regarding insulin administration. The physician had ordered that Insulin Lispro be held if the resident's blood sugar was less than 140 mg/dL. Despite this order, the Medication Administration Records (MARs) for December 2024 and January 2025 showed that Resident 32 received insulin on multiple occasions when their blood sugar levels were below the specified threshold. Specifically, insulin was not held on several dates when the resident's blood sugar ranged from 83 mg/dL to 133 mg/dL. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging that the insulin was not held as ordered.
Unsanitary Food Service Conditions
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as observed during multiple inspections of the main kitchen. On three separate occasions, surveyors noted an accumulation of dust and food debris under and behind the ice machine and stove. Additionally, a clear drinking glass, a small red bowl, and a [NAME] Cup were found under and behind the ice machine. These observations were confirmed by an interview with the Dietary Manager, who acknowledged the presence of dust, food debris, and the misplaced items.
Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, inadequate development of comprehensive person-centered care plans, and issues related to the quality of care. Additionally, the facility struggled with accountability for controlled medications, preventing significant medication errors, and ensuring food was procured, stored, prepared, and served under sanitary conditions. The facility had previously developed plans of correction for these issues, which included conducting audits and reporting results to the QAPI committee. However, the current survey revealed that these plans were ineffective, as the same deficiencies were cited again. The QAPI committee's inability to implement successful corrective actions resulted in ongoing non-compliance with regulations, as indicated by the repeated citations under F641, F656, F684, F755, F760, and F812.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically involving Resident 19. Resident 19, who had a history of a psychotic disorder and schizophrenia, was involved in an incident where Nurse Aide 1 verbally abused the resident. The incident was reported by Registered Nurse Supervisor 2, who overheard Nurse Aide 1 making inappropriate comments to Resident 19, including a statement about the resident's genitalia and urination on the floor. Despite hearing this, Registered Nurse Supervisor 2 did not immediately report the incident to the Nursing Home Administrator or Director of Nursing, citing that Nurse Aide 1 does not listen. The investigation revealed that Nurse Aide 1 admitted to making a comment about the resident's behavior but denied using swear words. Resident 19 was unable to recall the incident, and other residents in the area reported hearing a loud voice but could not confirm the content of the conversation. The facility's abuse policy mandates that all residents be treated with kindness and respect, free from any form of abuse. The failure to immediately address and report the verbal abuse incident led to the deficiency being cited as past non-compliance.
Failure to Timely Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse involving two residents. Resident 19, who has a history of a psychotic disorder and schizophrenia, was allegedly verbally abused by Nurse Aide 1. The incident was overheard by Registered Nurse Supervisor 2, who did not immediately report it to the Nursing Home Administrator or Director of Nursing as required by the facility's abuse policy. The verbal abuse involved inappropriate language directed at the resident, but the resident could not recall the incident when interviewed. Another incident involved Resident 136, who has a history of a hip fracture and chronic obstructive pulmonary disease. Nurse Aide 1 was again accused of verbal abuse, this time for using inappropriate language after the resident spilled water on herself. Nurse Aide 3 overheard the incident but did not report it until several hours later, after consulting with a union representative. The resident did not recall the incident when interviewed, and other staff members did not witness the exchange. The facility's policy requires immediate notification of the Nursing Home Administrator or Director of Nursing in cases of suspected abuse. However, both Registered Nurse Supervisor 2 and Nurse Aide 3 failed to adhere to this protocol, resulting in a delay in addressing the allegations. The incidents were eventually reported, but the delay in reporting violated the facility's abuse policy and procedures.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of medication administration. For Resident 14, physician's orders indicated the administration of gabapentin, an anticonvulsant medication, twice daily and at bedtime for rheumatoid arthritis. However, the MDS assessment inaccurately recorded that the resident did not receive any anticonvulsant medication during the seven-day assessment period. Similarly, Resident 24 was prescribed Seroquel, an antipsychotic medication, to be taken daily, but the MDS assessment incorrectly noted that no antipsychotic medication was administered. Resident 32 was ordered to receive gabapentin three times a day for polyneuropathy, and the Medication Administration Records (MARs) confirmed this administration. Despite this, the MDS assessment for Resident 32 also inaccurately indicated that no anticonvulsant medication was given during the assessment period. These inaccuracies were confirmed during an interview with the Nursing Home Administrator, highlighting a failure in the facility's assessment process as per the guidelines in the Resident Assessment Instrument User's Manual.
Failure to Develop EBP Care Plan for Resident with Drain
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident who was on Enhanced Barrier Precautions (EBP) due to a surgically implanted percutaneous drain. The resident, who was cognitively intact and dependent on staff for daily care tasks, had physician's orders prohibiting showers and requiring daily vigorous flushing of the gallbladder drain. Despite these specific care needs, there was no documented evidence of a care plan addressing the resident's EBP requirements. Observations confirmed the presence of EBP signage and personal protective equipment outside the resident's room, and staff interviews acknowledged the need for gown use when providing care. However, the Nursing Home Administrator confirmed the absence of a care plan addressing the resident's EBP needs.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to monitor a resident's weight as recommended by the dietitian, which led to a deficiency. The facility's policy required a re-weight to be obtained within 24 hours if a significant weight change was noted. Resident 14, who was moderately cognitively impaired, experienced a weight loss from 127.4 pounds to 117.8 pounds between December 13, 2024, and January 1, 2025. A dietitian noted the significant weight change on January 9, 2025, and requested a re-weight, but there was no documented evidence that this re-weight was obtained. Subsequently, on January 16, 2025, the resident's weight was recorded as 136.2 pounds, indicating a gain of 18.4 pounds. However, a re-weight was not documented until January 21, 2025, when the resident's weight was 116.4 pounds. An interview with the Director of Nursing and Nursing Home Administrator confirmed that the re-weights were not conducted according to the dietitian's recommendations or the facility's policy.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. A quarterly Minimum Data Set (MDS) assessment for the resident revealed that they were understood, could understand others, and had a diagnosis of anxiety. The care plan indicated the use of anti-anxiety medications as ordered by the physician. Physician's orders included a prescription for Clonazepam, a narcotic medication, to be administered every eight hours as needed. However, the controlled drug logs for January and February showed that staff signed out doses of Clonazepam for administration on several specific dates and times. Despite this, there was no documented evidence in the resident's clinical record, including the Medication Administration Records (MARs) and nursing notes, that the Clonazepam was actually administered on those dates and times. An interview with the Nursing Home Administrator confirmed the lack of documentation for the administration of the medication.
Failure to Attempt Non-Pharmacological Interventions Before Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to a resident. The resident, who was diagnosed with an anxiety disorder, had a care plan that required staff to try non-medication interventions such as massage, music, or quiet time before offering as-needed psychotropic medication. Despite this, the resident was frequently administered Clonazepam without documented evidence of attempting these non-pharmacological methods first. The resident's Medication Administration Records for January and February 2025 showed multiple instances where Clonazepam was given for anxiousness or restlessness, yet there was no documentation of non-medication interventions being tried beforehand. An interview with the Nursing Home Administrator confirmed the lack of documentation for these interventions, indicating a failure to adhere to the care plan and regulatory requirements.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated and revised to reflect their specific care needs. For Resident 1, the care plan indicated the use of oxygen for a respiratory illness, but observations revealed no oxygen in the room, and the resident did not have orders for oxygen use. Additionally, the care plan for fall prevention was inaccurate, as it specified a fall mat on the right side of the bed, while the mat was observed on the left side. The Director of Nursing confirmed these discrepancies and acknowledged that the care plan should have been updated accordingly. Resident 4's care plan included a focus on a Stage 2 pressure ulcer to the sacrum, which was resolved as per a nurse's note, but the care plan was not updated to reflect this resolution. Similarly, Resident 12's care plan indicated a risk for self-injury related to a PEG tube, which had been removed, but the care plan was not updated. The Director of Nursing confirmed that the care plans for both residents should have been updated to reflect their current conditions.
Failure to Follow Physician's Orders for Medications
Penalty
Summary
The facility failed to ensure that physician's orders for medications were followed for three residents. Resident 1, who was cognitively impaired and had diagnoses including heart failure, high blood pressure, and dementia, had physician's orders to monitor blood pressure before administering certain medications. However, there was no documented evidence that the blood pressure was being monitored as required. This was confirmed by the Director of Nursing during an interview. Resident 4, who was cognitively intact and had a Stage 2 pressure ulcer, had a physician's order to receive a nutritional supplement, Expedite, for 14 days or until the wound was healed. Despite the wound being resolved, the resident continued to receive the supplement for 22 days beyond the resolution. Resident 12, who was cognitively impaired and had diagnoses including heart failure, respiratory failure, and chronic obstructive pulmonary disease, had physician's orders to monitor blood pressure and heart rate before administering Metoprolol. There was no documented evidence that these vital signs were being monitored, which was also confirmed by the Director of Nursing.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents. For Resident 1, who was cognitively impaired and had diagnoses including heart failure and dementia, there were multiple instances where Tramadol was signed out but not documented as administered in the Medication Administration Record (MAR) or nursing notes. The Director of Nursing confirmed the lack of documentation for these doses during an interview. Similarly, Resident 30, who was cognitively intact and had diagnoses including pulmonary fibrosis and anxiety disorder, had several doses of Lorazepam signed out without corresponding documentation of administration in the MAR or nursing notes. This was also confirmed by the Director of Nursing during an interview. Lastly, Resident 31, who was cognitively intact and had undergone spinal fusion surgery, had multiple doses of Oxycodone signed out without documented evidence of administration in the MAR or nursing notes. The Director of Nursing confirmed this deficiency as well during an interview. The facility's policy on medication administration requires that all administered medications be documented on the MAR, including the initials and time of administration for as-needed medications. However, the review of clinical records and controlled drug records for the three residents revealed a failure to adhere to this policy. The lack of documentation for the administration of controlled medications such as Tramadol, Lorazepam, and Oxycodone indicates a significant lapse in maintaining accountability for these drugs, which have a high potential for abuse. This deficiency was confirmed through staff interviews and a review of the facility's policies and clinical records.
Failure to Maintain Clean Wheelchair
Penalty
Summary
The facility failed to ensure a clean and homelike environment for Resident 18, who was moderately cognitively impaired, required assistance for daily care needs, had impairment on one side of the upper and lower extremities, and used a wheelchair. Observations on two separate occasions revealed that Resident 18's wheelchair had a dried, brown/tan, removable substance on the metal bars. Interviews with nurse aides confirmed the presence of the substance and indicated that there was no routine cleaning schedule for wheelchairs. The Director of Nursing stated that wheelchairs were power washed twice a year, but Resident 18's wheelchair had a removable substance that should have been cleaned.
Failure to Verify Professional Licensure
Penalty
Summary
The facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hiring a Licensed Practical Nurse (LPN). The facility's abuse policy, dated October 12, 2023, required that all staff meet regulatory standards for hire, including verification of nursing licenses. However, the personnel file for an LPN hired on January 4, 2024, showed that as of April 2, 2024, the licensure verification had not been completed. This was confirmed by the Director of Nursing during an interview on April 2, 2024, at 11:39 a.m. The failure to verify the LPN's professional licensure was a violation of the facility's own policies and state regulations.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized care plans that included resident-centered interventions for two residents. Resident 23, who was cognitively intact and frequently incontinent of bowel and bladder, did not have a care plan addressing his bladder incontinence. This was confirmed by the Director of Nursing during an interview, and it was noted that the care plan should have been developed based on the resident's needs and the facility's policy. Similarly, Resident 30, who was cognitively intact and had multiple diagnoses including pulmonary fibrosis, respiratory failure, and COPD, did not have a care plan addressing the need for long-term antibiotic therapy. Despite physician's orders for the resident to receive sulfamethoxazole-trimethoprim, there was no documented evidence of a care plan for this treatment. The Director of Nursing confirmed the absence of the care plan during an interview, acknowledging that it should have been in place.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for a resident who was at risk for falls. The resident, who was cognitively impaired and required assistance for daily care needs, had a history of tripping over oxygen tubing due to poor balance. A care plan intervention required the use of a tether alarm to prevent falls. However, during an observation, it was found that the alarm was not attached to the resident as required by the care plan. The deficiency was confirmed through staff interviews and observations. The resident was observed lying in bed with the alarm on the enabler bar but not attached to her. An LPN confirmed that the alarm should have been attached to the resident. The Director of Nursing also confirmed that the alarm should have been in place, indicating a failure to follow the care plan designed to minimize fall risks for the resident.
Failure to Obtain Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order was obtained to provide oxygen therapy for two residents. Resident 12, who was cognitively impaired and had diagnoses including heart failure, respiratory failure, and chronic obstructive pulmonary disease, was observed using supplemental oxygen at 3 liters per minute without a corresponding physician's order. The Director of Nursing confirmed that there was no physician's order for the oxygen therapy being administered to Resident 12, despite the care plan indicating the need for oxygen due to chronic obstructive pulmonary disease. Similarly, Resident 30, who was cognitively intact and had diagnoses including pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease, was observed using supplemental oxygen at 7 liters per minute without a physician's order. The Director of Nursing also confirmed that there was no physician's order for the oxygen therapy being administered to Resident 30, despite the care plan indicating the need for oxygen due to her medical conditions. These findings indicate a failure to adhere to the facility's policy for oxygen administration, which requires a physician's order for such therapy.
Failure to Adhere to Physician's Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one of the residents reviewed. Resident 12, who was cognitively impaired and required assistance for daily care needs, had a physician's order to receive 5 units of Novolog insulin before meals, with the instruction to hold the insulin if the Accucheck reading was 150 mg/dL or less. However, the review of the March 2024 Medication Administration Record (MAR) revealed that the resident received 5 units of Novolog insulin on multiple occasions despite having blood sugar levels below the specified threshold. Specifically, the insulin was administered at 8:00 a.m. on March 1, 2, 7, 13, 17, 18, 25, and 31, and at other times on March 2, 7, 12, 13, 21, and 31, even though the blood sugar readings were below 150 mg/dL on these dates. An interview with the Director of Nursing on April 2, 2024, confirmed that the parameters set by the physician's orders were not followed on 14 occasions, resulting in the administration of Novolog insulin to Resident 12 when it should have been withheld. This failure to adhere to the physician's orders constitutes a significant medication error, as the insulin was given despite the resident's blood sugar levels being below the threshold specified in the orders.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to discard two expired multi-dose insulin vials and did not securely store medication in the medication cart on B Hall. During a medication pass, an LPN left a card of Januvia tablets unsupervised on top of the medication cart while entering a resident's room. Additionally, the medication cart was observed to be left unlocked with no staff in view. The Director of Nursing confirmed that medications should not be left unsupervised and the cart should be locked when not in use or view. Further observations revealed that a multi-use vial of Lantus insulin for one resident was not labeled with the date it was opened, and another vial for a different resident was labeled with an expired date but not discarded. The LPN confirmed that the insulin should have been labeled when opened and discarded after expiration. The Director of Nursing also confirmed these findings, indicating that the facility's policies were not followed regarding medication labeling and storage.
Expired Food Item Not Discarded
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety by not discarding an opened, expired food item. The facility's policy required staff to date food items when opened and discard them by the stamped expiration date. During an observation in the small kitchen refrigerator, an opened container of Miracle Whip salad dressing with a resident's name on it was found without a use-by date and with a stamped expiration date that had passed. The Dietary Manager confirmed that the expired item should have been discarded but was not.
Repeated Deficiencies in Quality Assurance and Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and maintain compliance with quality deficiencies identified in previous surveys. The deficiencies were related to comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food procurement-storing/preparing/serving food under sanitary conditions. Despite developing plans of correction that included quality assurance systems and audits, the facility did not achieve ongoing compliance with these regulations as evidenced by repeated deficiencies in the current survey. The deficiencies were identified in multiple areas, including comprehensive care plans (F656), care plan timing and revision (F657), quality of care (F684), safe environment/supervision (F689), respiratory care (F695), pharmacy services (F755), labeling and storage of drugs/biologicals (F761), and food procurement-storing/preparing/serving food under sanitary conditions (F812). The facility's QAPI committee was responsible for reviewing audit results and ensuring compliance, but the current survey revealed that the committee failed to maintain ongoing compliance with these regulations, leading to repeated deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 291 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Johnstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Ridge Senior Living At Johnstown | 0.1 mi | ★★★★★ | 21 | 1 |
| Hilltop Heights Health & Rehab Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Conemaugh Memorial Medical Center Tcu | 2 mi | ★★★★★ | 2 | 0 |
| Concordia At Arbutus Park | 3.9 mi | ★★★★★ | 14 | 0 |
| Laurel View Village | 4.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.