Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wesbury United Methodist Commu during CMS and state inspections, most recent first.
Hospice plans of care and visit notes were not current for three residents receiving hospice services. The records for residents with diagnoses including Alzheimer’s disease, aphasia, Parkinsonism, stroke, psychosis, and difficulty swallowing showed outdated hospice documentation, and LPNs confirmed that two residents’ hospice care plans were not current and that recent hospice staff visit notes were missing.
Improper care and dating of respiratory equipment affected multiple residents. A DON confirmed that several residents’ nasal cannulas and HHN devices were not changed per facility protocol, with tubing and nebulizer equipment observed dated beyond the required change intervals and, in one case, an HHN left on a bedside stand rather than stored in a zip-lock style bag. The affected residents had diagnoses including COPD, asthma, chronic respiratory failure, pneumonia, and dependence on supplemental oxygen.
An LPN failed to perform hand hygiene and change gloves during wound care, and respiratory equipment for two residents was left unsecured or handled improperly, including oxygen tubing on beds or the floor and a HHN hanging outside storage bags. In another instance, a nurse aide did not wear required EBP PPE while assisting a resident with bathroom care, and the aide and LPN confirmed the PPE was not used as required.
A resident with a left femur fracture, muscle weakness, difficulty walking, and orthopedic aftercare was transferred to the hospital, but the clinical record lacked documentation that the resident and/or representative received the required bed-hold policy notice explaining bed-hold duration and daily cost. The record also lacked evidence that necessary resident information was communicated to the receiving hospital, and the DON confirmed both omissions.
Care plan not updated after major fall injury: A resident with heart disease, muscle weakness, vascular dementia, altered mental status, and age-related debility had an unwitnessed fall that later resulted in a fractured clavicle. Although the fall investigation said the care plan was updated, the Falls care plan did not show what was changed and did not reflect the major injury, and the NHA confirmed the plan still had the same goal date.
Incomplete Investigation of Unwitnessed Fall: A resident with heart disease, muscle weakness, vascular dementia, altered mental status, and age-related debility had an unwitnessed fall that was later associated with a fractured clavicle. The facility’s investigation lacked documentation of interviews with the resident, staff, or other witnesses, and the NHA confirmed there was no additional documentation showing the fall was thoroughly investigated.
Incomplete fluid intake documentation for a resident receiving tube feeding and ordered water flushes. The resident had diagnoses including hyperosmolality, hypernatremia, urine retention, and dysphagia, and the MAR documented the ordered flushes and Jevity infusion, but the fluid intake section did not clearly state whether to include or exclude the flushes, enteral feeding, or medication-related water flushes. The DON confirmed the MAR lacked clear 24-hour fluid intake parameters and that the documentation of water intake had a wide gap.
The facility failed to timely review and revise care plans for three residents, as required by its policy. The care plans were not updated to reflect current care and services, despite changes in residents' conditions and scheduled reviews. The Director of Nursing confirmed this deficiency during an interview.
A facility failed to obtain a physician's order for oxygen therapy for a resident with a history of cerebral infarction and other medical conditions. The resident was observed receiving oxygen therapy without a specific physician's order, despite facility policy requiring notification and an order. The DON confirmed the lack of a physician's order for the therapy being administered.
A facility failed to adhere to its policy requiring a 14-day stop date or clinical rationale for PRN psychotropic medications. A resident with anxiety, dementia, and muscle weakness was prescribed Lorazepam without the necessary documentation. The DON confirmed the oversight, highlighting non-compliance with policy and regulations.
The facility did not discard an expired Tubersol PPD vial in the College Way medication room as per policy and manufacturer's guidelines. An LPN confirmed the vial was past its 30-day usage period, highlighting a failure to adhere to proper medication management protocols.
A facility failed to implement Enhanced Barrier Precautions (EBPs) for a resident with a gastric feeding tube, as required by their policy. The resident, who had dysphagia and gastrostomy complications, was observed without the necessary EBPs in place during a medication administration. The Infection Preventionist confirmed that staff should have been wearing gloves and gowns, highlighting a deficiency in infection control practices.
Hospice Plans of Care and Visit Notes Were Not Current
Penalty
Summary
The facility failed to maintain current hospice information in the clinical records for three residents who were receiving hospice services. The Skilled Nursing Facility Inpatient Care Services Agreement required the hospice to communicate changes in condition that required updates to the plan of care and to provide the SNF with the updated plan of care, and required that communication between the hospice and SNF be documented in the resident’s clinical record. However, the most recent hospice staff visit notes and hospice plans of care in the records for Residents R27, R77, and R122 were not current. Resident R27 had diagnoses including Alzheimer’s Disease, difficulty swallowing, difficulty walking, and aphasia, and a physician’s order indicated hospice admission effective 11/17/2025. The most recent hospice staff visit notes in the record were dated 6/18/26, and the hospice plan of care ended on 7/14/26. Resident R77 had diagnoses including adult failure to thrive, Parkinsonism, aphasia, and stroke, and a physician’s order indicated hospice admission effective 10/03/25; the most recent hospice staff visit notes were dated 7/01/26, and the hospice plan of care ended on 5/29/26. Resident R122 had diagnoses including psychosis, difficulty swallowing, Alzheimer’s Disease, and Barrett’s Esophagus, and a physician’s order indicated hospice admission effective 1/24/24; the most recent hospice staff visit notes were dated 6/20/26. LPN staff confirmed that R27’s hospice care plan was not current and that the clinical record lacked recent hospice staff visit notes, and that R77’s hospice care plan was not current and the clinical record lacked recent hospice staff visit notes, and that R122’s clinical record lacked recent hospice staff visit notes.
Improper care and dating of respiratory equipment
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment and failed to help prevent the spread of infection related to respiratory care equipment for six residents. Facility policy required oxygen nasal cannula tubing, masks, extension tubing, and zip-lock style bags to be changed every week, and HHN equipment to be rinsed, air dried, stored in a zip-lock style bag, and the HHN apparatus changed bi-weekly and as needed. Review of records and observations showed that Resident R2, who had CHF, COPD, muscle weakness, dysphagia, and a gastrostomy, was receiving oxygen at 2 LPM via nasal cannula with a date of 7/26 written on the tubing, but the record lacked evidence that the tubing had been changed. Resident R12, who had COPD and acute respiratory failure, was ordered oxygen at 2 LPM via nasal cannula at bedtime, and the tubing was observed dated 6/17/26 with no evidence it had been changed. Resident R133, who had asthma and obstructive sleep apnea, was ordered oxygen at 2 LPM at bedtime, and the nasal cannula was observed dated 7/26 with no evidence it had been changed. The same issue was identified with HHN equipment for two residents. Resident R81, who had COPD, chronic respiratory failure, and asthma, was ordered Albuterol Sulfate via HHN three times daily, but the HHN was observed lying on the bedside stand dated 6/26 and not stored in a zip-lock style bag, with no evidence it had been changed. Resident R92, who had pneumonia and anxiety, was ordered Ipratropium/Albuterol nebulization via HHN four times daily as needed, and the HHN was observed in a zip-lock style bag taped to the bedside stand dated 6/26, with no evidence it had been changed. Resident R138, who had COPD, muscle weakness, dependence on supplemental oxygen, and a UTI, was ordered oxygen at 3 LPM every shift, and the nasal cannula was observed dated 7/26 with no evidence it had been changed. The DON confirmed that the nasal cannulas and HHNs for the identified residents should have been changed per facility protocol.
Infection Control Lapses During Wound Care, Respiratory Equipment Handling, and EBP Use
Penalty
Summary
The facility failed to prevent potential cross contamination during wound care for one resident. The resident had an admission date of 4/15/26 and diagnoses that included hyperosmolality, hypernatremia, urine retention, and difficulty swallowing. During observation of wound care on 7/22/26, an LPN removed the soiled dressing from the resident’s lower back, changed gloves, and did not perform hand hygiene. Later in the same observation, the LPN removed the soiled dressing from the resident’s right ear and again failed to perform hand hygiene and change gloves before dating the tape of the new dressing, cleansing the wound, and applying the new dressing. The LPN confirmed that hand hygiene and glove changes should have been performed when discarding the soiled dressings. The facility also failed to maintain sanitary respiratory equipment for two residents who had orders for oxygen and nebulizer treatments. One resident, admitted 5/19/26 with diagnoses including stroke, ataxia, COPD, dependence on supplemental oxygen, and long-term respiratory failure with hypoxia, had oxygen tubing with a nasal cannula lying on top of an unmade bed and a HHN hanging by its elastic strap over the nebulizer machine door rather than being stored in zip lock type bags. The same condition was observed again later, with the tubing on the made bed and the HHN still hanging over the machine door. An LPN confirmed that the oxygen tubing and HHN should be placed in plastic bags when not in use. A second resident, admitted 5/26/23 with diagnoses including Alzheimer’s Disease, COPD, dependence on supplemental oxygen, and long-term respiratory failure with hypoxia, was observed self-propelling in a wheelchair with oxygen tubing dragging on the floor while the portable oxygen tank was turned on. A nurse aide picked up the nasal cannula and placed it against the resident’s face to reapply it, then draped the tubing over the wheelchair handle and walked away. The nurse aide confirmed the nasal cannula should be cleansed before reapplying. In addition, a resident with an order for EBP every shift and a care plan intervention for staff to wear PPE as appropriate was observed being assisted from the bathroom by a nurse aide who was not wearing EBP. The nurse aide confirmed not wearing a gown and acknowledged that PPE was usually hanging on the back of the room door, and the LPN confirmed the aide did not implement EBP during high-contact care.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide Resident R1 and/or the resident representative with a written bed-hold policy notice upon or within 24 hours of transfer to the hospital, including how long the bed could be held during a leave of absence and the cost per day. Resident R1 was admitted on 9/22/22 with diagnoses including left femur fracture, muscle weakness, difficulty walking, and orthopedic aftercare, and was transferred to the hospital on 4/20/26. The clinical record lacked documentation that the bed-hold policy was provided and lacked evidence that necessary resident information was communicated to the receiving hospital. During interview, the DON confirmed that the resident and/or representative were not given the bed-hold policy and that the record did not show communication of necessary resident information to the receiving health care provider.
Care plan not updated after major fall injury
Penalty
Summary
The facility failed to review and revise a comprehensive care plan to reflect the current necessary care and services for one resident. Facility policy stated that care plans are to be updated when a resident has a change in condition or when scheduled by the MDS team for quarterly, change in condition, or annual review. Another policy stated that when a resident is found on the floor, the facility must investigate how the resident got there and put interventions in place to prevent recurrence. The resident had diagnoses including heart disease, muscle weakness, vascular dementia, altered mental status, and age-related debility, and was admitted on 3/17/26. The resident had an unwitnessed fall on 4/12/26 at 10:15 p.m., and later testing on 4/15/26 identified a fractured right clavicle. The fall investigation dated 4/12/26 stated that the resident's care plan was updated, but it did not document what was updated. The Falls care plan contained interventions dated 3/17/26 and a goal date of 6/15/26, but it did not show updates related to the fall with major injury. The Nursing Home Administrator confirmed on 7/23/26 that the Falls care plan did not reflect updates related to the major fall injury and that the goal date remained 6/15/26.
Incomplete Investigation of Unwitnessed Fall
Penalty
Summary
The facility failed to completely investigate an unwitnessed fall for one resident. Facility policies stated that the charge nurse or registered nurse would complete an incident report and investigate the circumstances of the incident, including speaking with nursing assistants, residents, and any other witnesses. Review of the resident’s clinical record showed an admission date of 3/17/26 with diagnoses including heart disease, muscle weakness, vascular dementia, altered mental status, and age-related debility. The resident experienced an unwitnessed fall on 4/12/26 at 10:15 p.m., and later diagnostic testing on 4/15/26 identified a fractured right clavicle. Review of the facility’s investigation for the fall showed no evidence of interviews with the resident, staff, or other witnesses. During an interview on 7/23/26 at 12:40 p.m., the Nursing Home Administrator confirmed there was no additional documentation showing that the fall had been thoroughly investigated.
Incomplete Fluid Intake Documentation for Tube-Feeding Resident
Penalty
Summary
The facility failed to have complete, accurate, and systematically organized documentation regarding the administration of additional water ordered for tube feeding for one resident. The resident had diagnoses including hyperosmolality, hypernatremia, urine retention, and difficulty swallowing, and had physician orders for fluid intake provided by nursing each shift, water flushes before and after medications, water flushes every shift, water flushes four times per day, and Jevity 1.5 Cal tube feeding at 50 mL per hour starting at 11:00 a.m. daily. Review of the resident’s MAR showed nursing documented the ordered water flushes and tube feeding, but the MAR documentation for fluid intake provided by nursing each shift did not clearly direct staff to include or exclude the 100 mL flushes every shift and four times per day, the Jevity infusion, or the 30 mL flushes before and after medications. This resulted in inaccurate and inconsistent documentation of fluid intake provided by nursing staff each shift. The facility’s Fluid Management Report for the resident showed 24-hour fluid intake totals ranging from 910 mL to 2340 mL, and the DON confirmed that the 24-hour fluid intake parameters were not clearly written on the MAR and that there was a wide gap in the documentation of water intake.
Failure to Timely Update Resident Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for three residents. The facility's policy requires care plans to be updated whenever there is a change in a resident's condition, physician orders, or during scheduled reviews by the MDS team. However, the care plans for Residents R27, R88, and R100 were not updated in a timely manner. Resident R27's care plan had not been reviewed since 5/9/24, despite a goal date of 8/7/24. Resident R88's care plan had a goal date of 7/25/24, but the last care plan meeting note was a late entry dated 8/15/24. Similarly, Resident R100's care plan had a goal date of 8/1/24, with the last care plan note being a late entry dated 5/10/24 for a meeting on 5/03/24. The Director of Nursing confirmed during an interview that the care plans for these residents were not reviewed and revised in a timely manner to reflect their current care and services. This deficiency was identified based on a review of facility policy, clinical records, and staff interviews. The facility's failure to adhere to its policy on updating care plans as necessitated by changes in residents' conditions or scheduled reviews led to this deficiency.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the provision of oxygen therapy for a resident, identified as Resident R123, who was reviewed for respiratory services. The facility's policy on oxygen therapy, last reviewed in June 2024, states that oxygen may be administered as a nursing measure without a physician's order, but the physician must be notified and an order received. However, Resident R123's clinical record lacked evidence of a physician's order specifying the amount of oxygen to be delivered, despite the resident being observed wearing an oxygen nasal cannula connected to an oxygen concentrator delivering 2 liters per minute. Resident R123 was admitted with diagnoses including a gastrostomy complication, contractures of both hands, and a history of cerebral infarction. The clinical record contained an order from July 2023 to assess for oxygen use every shift, but did not include a specific order for the oxygen therapy being administered. The Director of Nursing confirmed during an interview that the resident was receiving oxygen therapy without a physician's order for the specific therapy, which constitutes a deficiency in the facility's compliance with respiratory care protocols.
Failure to Document PRN Psychotropic Medication Stop Date
Penalty
Summary
The facility failed to comply with its policy regarding the administration of PRN psychotropic medications, specifically for Resident R29. The policy mandates that psychotropic medications, excluding antipsychotics, prescribed on a PRN basis must have a 14-day stop date unless a clinical rationale for extending the order is documented. Resident R29, who has diagnoses including anxiety, dementia, and muscle weakness, was prescribed Lorazepam 0.5 mg every 4 hours as needed for anxiety. However, the order, dated 8/02/24, did not include the required 14-day stop date or a documented clinical rationale for its continued use beyond this period. During an interview, the Director of Nursing confirmed the absence of the required stop date or clinical rationale in Resident R29's Lorazepam orders, indicating a failure to adhere to the facility's policy and regulatory requirements.
Expired Medication Not Discarded Timely
Penalty
Summary
The facility failed to discard an expired medication in a timely manner in one of its medication rooms, specifically the College Way medication room. A review of the facility's policy on medications and the manufacturer's recommendations for Tubersol PPD, a solution used for tuberculosis testing, indicated that vials should be discarded after 30 days of being opened. During an observation of drug storage, an opened vial of Tubersol was found in the refrigerator with an open date exceeding 30 days. A Licensed Practical Nurse confirmed that the medication was expired and should have been discarded, indicating a lapse in following the facility's policy and manufacturer's guidelines.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to implement infection control practices regarding Enhanced Barrier Precautions (EBPs) for a resident with a gastric feeding tube. The facility's policy, implemented in March 2024, requires all staff providing direct resident care to adhere to EBPs, in addition to standard precautions, when performing high-contact resident care activities for residents with wounds, indwelling medical devices, and/or suspected or confirmed infection or colonization of certain multi-drug resistant organisms (MDROs). EBPs are designed to reduce the transmission of resistant organisms and expand the use of gowns and gloves during high-contact resident care activities. However, during an observation on August 14, 2024, it was noted that EBPs were not in place for Resident R123, who had a gastric feeding tube. Resident R123's clinical record indicated an admission with diagnoses including dysphagia, gastrostomy complications, and muscle weakness. During a medication administration observation for the gastric feeding tube, it was confirmed by the Infection Preventionist that employees were not wearing gloves and gowns as required by the facility's policy. This oversight was identified as a deficiency in the facility's infection control practices, specifically regarding the implementation of EBPs for residents with indwelling medical devices like feeding tubes.
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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.
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Nursing homes near Meadville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadville Medical Ctr Tcu | 0.7 mi | ★★★★★ | 6 | 0 |
| Embassy Of Park Avenue | 2.2 mi | ★★★★★ | 13 | 0 |
| Crawford Care Center | 4.6 mi | ★★★★★ | 18 | 1 |
| Rolling Fields, Inc | 12.9 mi | ★★★★★ | 19 | 0 |
| Edinboro Manor | 16.6 mi | ★★★★★ | 22 | 0 |
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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 October 2026) and official state health department websites.