Westgate Hills Rehabilitation And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Havertown, Pennsylvania.
- Location
- 2050 Old West Chester Pike, Havertown, Pennsylvania 19083
- CMS Provider Number
- 395173
- Inspections on file
- 20
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Westgate Hills Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
A resident's room was found to have a window with broken glass pieces taped with duct tape and additional broken glass between the glass panel and screen. The same room also contained a dresser with two broken drawer fronts, with the broken pieces left inside the drawers. These issues were confirmed by the DON during observation, indicating a failure to provide a safe environment.
The facility failed to maintain its sprinkler system, with deficiencies including non-reporting tampers, an overdue FDC hydrotest, and an improperly piped dry system main drain. These issues were confirmed during document reviews and exit interviews with facility administrators.
The facility failed to maintain the fire rating of a storage area on the first floor near a resident room, as it lacked a self-closing door. This deficiency was observed on two separate occasions and confirmed by facility administrators.
The facility failed to conduct monthly inspections of the kitchen hood suppression system on the first floor, as required by NFPA 101. This deficiency was initially observed in November and confirmed during an exit interview with the Administrator and Maintenance Director. A revisit in January showed the issue persisted, confirmed again in an exit interview with the Administrator and Regional Maintenance Director.
Westgate Hills Rehabilitation and Nursing Center was found deficient in their Emergency Preparedness Plan, lacking policies and procedures for persons at-risk. This issue was identified during a document review and confirmed in interviews with the Administrator and Maintenance Director. A subsequent revisit showed the deficiency remained unaddressed.
The facility failed to provide necessary policy and procedure documentation regarding its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was identified during a document review and confirmed in interviews with the Administrator and Maintenance Director. A follow-up revisit showed the issue remained unaddressed.
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was confirmed during document reviews and exit interviews with facility administrators, indicating non-compliance with the requirement to review and update the program annually.
The facility failed to conduct one of the two required annual exercises to test its emergency preparedness plan, as revealed during a document review. Despite performing a full-scale exercise, the facility did not conduct the additional required exercise, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, and a follow-up revisit showed the issue remained unaddressed.
The facility failed to maintain and inspect portable fire extinguishers as per NFPA 10 standards. They could not provide certification for the inspector conducting the annual inspection, and a fire extinguisher was found blocked by wheelchairs. These issues were confirmed during interviews with the Administrator and Maintenance Director.
A facility failed to follow physician's orders for a resident's medication, Metoprolol, which was administered 23 times despite the resident's heart rate being below the prescribed threshold. The resident had Chronic Systolic Heart Failure and Paroxysmal Atrial Fibrillation, and the issue was confirmed by the DON and Nursing Home Administrator.
A resident experienced a significant weight loss while on enteral feeding, dropping 9.8 pounds in less than a month. The facility failed to re-weigh the resident or address the weight change in a timely manner, with the dietitian taking seven days to respond and the physician being notified two weeks later. This delay violated the facility's policy and regulatory requirements.
A facility failed to ensure that medication irregularities identified during monthly drug regimen reviews were acted upon by a physician for a resident with severely impaired cognition and multiple medical diagnoses. Despite recommendations from the pharmacist to evaluate the use of certain medications, the physician signed the reports without responding or indicating any action taken. This deficiency was confirmed by the DON.
Failure to Maintain Safe Resident Room Environment
Penalty
Summary
A deficiency was identified when observations and staff interviews revealed that a resident's room on the Rehabilitation Unit had a window with broken glass pieces that were taped with duct tape, and additional broken glass pieces were found between the glass panel and the screen. Further inspection of the same room showed a dresser with two broken drawer fronts, with the broken pieces placed inside the drawers. These conditions were confirmed by the DON during the observation. The facility failed to provide a safe environment for the resident as required by regulations.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire facility. During a document review on November 20, 2024, it was found that the fourth quarter sprinkler inspection revealed several deficiencies that had not been corrected. Specifically, the tampers in the backflow preventer pit were not reporting to the fire alarm panel, the FDC hydrotest was overdue, and the dry system main drain was improperly piped to a shower drain that could not handle the full flow from the drain. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the same deficiencies remained unaddressed. The tampers in the backflow preventer pit still did not report to the fire alarm panel, the FDC hydrotest was still overdue, and the dry system main drain continued to be piped to a shower drain incapable of handling the full flow. These ongoing deficiencies were again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K353: Sprinkler System Maintenance and Inspection 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the following deficiencies noted during the fourth quarter sprinkler inspection, with no documentation of the correction of these issues: a. Tampers in the backflow preventer pit were not reporting to the fire alarm panel. b. FDC hydrotest is overdue. c. Dry system main drain is piped to a shower drain, which cannot handle the full flow from the drain (note: this was not considered a deficiency, but a note). Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected if these issues with the sprinkler system are not addressed properly, as the sprinkler system is a key safety feature for the entire facility. 2. Corrective Action: a. The necessary repairs will be made to ensure that the tampers in the backflow preventer pit report to the fire alarm panel. This repair will be completed by 02/08/25. b. The FDC hydrotest was completed on 12/27/24. c. The issue with the dry system main drain was identified as a note by the inspector and is not considered a deficiency. An addendum to the original report will be obtained from the sprinkler inspection vendor indicating that the main drain item is not considered a "deficiency" and was identified as a note. This documentation will be available to review by the life safety inspector on the day of the revisit. 3. Monitoring: The Maintenance Director will ensure that the sprinkler system, including the backflow preventer and fire alarm panel connections, is fully functional and reporting correctly. A follow-up audit will be conducted on 02/08/25 to ensure all necessary corrections have been completed and that the sprinkler system is in full compliance. 4. Timeline: The repairs for the tampers in the backflow preventer pit will be completed by 02/08/25. The FDC hydrotest has been completed as of 12/27/24.
Failure to Maintain Fire Safety in Storage Area
Penalty
Summary
The facility failed to maintain the fire rating of storage areas, specifically on the first floor near resident room 131. During an observation on November 20, 2024, it was noted that the storage room lacked a self-closing mechanism on its door, which is a requirement for maintaining the fire resistance rating of hazardous areas. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the deficiency had not been corrected, as the storage room near resident room 131 still lacked a self-closing door. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director. The failure to address this issue indicates a continued non-compliance with the fire safety requirements for hazardous areas.
Plan Of Correction
Plan of Correction for TAG K321: Fire Safety - Storage Area Self-Closing Door 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain the fire rating of storage areas, affecting one of three levels within the facility. Observation on November 20, 2024, at 10:44 a.m., revealed that on the first floor, the storage room near resident room 131 lacked a self-closing door. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of a self-closing door. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of a fire emergency if fire safety regulations are not fully met. 2. Corrective Action: The self-closing door was installed in the storage room near resident room 131 to maintain the required fire rating for the area. The Maintenance Director verified that all other storage areas are in compliance with fire safety regulations. 3. Monitoring: Weekly audits will be conducted for 4 weeks to ensure continuous compliance with fire safety regulations, including verification of the self-closing door installation and proper function. Findings will be documented, and any necessary corrective actions will be taken. 4. Timeline: The self-closing door was installed on 01/08/25. Weekly audits will be completed for 4 weeks starting from 01/28/25.
Failure to Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which is a requirement under NFPA 101 for cooking facilities. During an observation on November 20, 2024, it was noted that the kitchen hood suppression system on the first floor lacked the necessary monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the issue persisted, as the kitchen hood suppression system still lacked monthly inspections. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K324: Kitchen Hood Suppression System 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of three levels in the facility. Observation on November 20, 2024, at 10:33 a.m., revealed that on the first floor, the kitchen hood suppression system lacked monthly inspections. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing monthly inspections. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the kitchen hood suppression system is not properly maintained and inspected in case of a fire emergency. 2. Corrective Action: The facility will conduct a thorough inspection of the kitchen hood suppression system immediately. Monthly inspections will be implemented going forward, and a log will be maintained to track the inspections. 3. Monitoring: The Maintenance Director will ensure that the kitchen hood suppression system is inspected monthly. Monthly audits will be conducted for 3 months to ensure compliance with the kitchen hood suppression system inspection requirement. 4. Timeline: The inspection will be completed by 01/28/25. Monthly inspections will continue, with audits conducted for 3 months to ensure ongoing compliance.
Deficiency in Emergency Preparedness Plan at Westgate Hills
Penalty
Summary
Westgate Hills Rehabilitation and Nursing Center was found to have deficiencies in their Emergency Preparedness Plan during a revisit survey. The facility failed to include policies and procedures addressing the patient population, specifically persons at-risk, in their emergency preparedness documentation. This deficiency was identified during a document review on November 20, 2024, and confirmed during an exit interview with the Administrator and the Maintenance Director. A subsequent onsite revisit conducted on January 8, 2025, revealed that the facility still had not addressed the missing documentation in their Emergency Preparedness Plan. The plan continued to lack policies and procedures for persons at-risk, affecting the entire facility. This was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG E0007: Emergency Preparedness Plan - Patient Population and Continuity of Operations 1. Deficiency: Based on document review and interview, the facility failed to ensure policies and procedures were in place addressing patient population, including but not limited to persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the Facility's Emergency Preparedness Plan did not include policies and procedures addressing persons at-risk. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency where these provisions are required. 2. Corrective Action: The facility will update its Emergency Preparedness Plan to include: - Policies and procedures addressing persons at-risk within the patient population. - A clear description of the types of services the facility is able to provide in the event of an emergency. - Continuity of operations, including delegation of authority and succession plans for key personnel to ensure continued operation during an emergency. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure it includes all necessary policies and procedures for the patient population, including those at risk, and for continuity of operations. Any updates or changes will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be updated by 01/28/25, with an annual review thereafter.
Failure to Provide Emergency Preparedness Documentation
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation concerning its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m., where it was found that the facility could not produce the required Emergency Preparedness Plan documentation. This documentation is crucial for outlining the facility's responsibilities in providing care and treatment at an alternate care site as identified by emergency management officials. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., revealed that the facility still had not addressed the issue, as the necessary documentation was still unavailable. This was further confirmed in an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day.
Plan Of Correction
Plan of Correction for TAG E0026 - Scope C: Emergency Preparedness Plan 1. Deficiency: A document review on November 20, 2024, at 8:00 a.m. revealed that the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the roles under a waiver declared by the Secretary. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency situation where the waiver provisions need to be implemented. 2. Corrective Action: The facility will review and update its Emergency Preparedness Plan to include: - Roles and responsibilities of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act. - Procedures for the provision of care and treatment at an alternate care site identified by emergency management officials, if necessary. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure continued compliance with updated policies and procedures. Any necessary updates will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be reviewed and updated by 1/28/25, with an annual review thereafter.
Failure to Develop Emergency Preparedness Training Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m. The review revealed that the facility did not have the necessary documentation to support the existence of such a program. This issue affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., confirmed that the facility still had not developed or maintained the required emergency preparedness training and testing program. The lack of documentation was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day. This ongoing deficiency indicates a failure to comply with the regulatory requirement to review and update the program at least annually.
Plan Of Correction
Plan of Correction for TAG E0036: Emergency Preparedness Training and Testing 1. Deficiency: Based on documentation review and interview, it was determined that the facility failed to develop an emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that aligns with the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's staff is not properly trained in emergency preparedness protocols. 2. Corrective Action: The facility will develop and implement an emergency preparedness training program based on the facility's updated emergency preparedness plan. The training program will include testing procedures and will be reviewed and updated at least annually to ensure ongoing compliance. 3. Monitoring: The facility will track and document all training sessions, including the participation of all relevant staff members. An annual review of the training program will be conducted to ensure that it remains aligned with the current emergency preparedness plan and includes all necessary updates. 4. Timeline: The emergency preparedness training program will be developed and implemented by 01/28/25, with annual reviews thereafter.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to meet the emergency preparedness testing requirements as outlined in §483.73(d)(2). Specifically, the facility did not conduct one of the two required annual exercises to test its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, which revealed that within the previous 12 months, the facility had only performed a full-scale exercise and did not conduct the additional required exercise. During an exit interview on the same day, the Administrator and the Maintenance Director confirmed the lack of an additional exercise. This oversight affected the entire facility, as the emergency preparedness plan was not fully tested as required by the regulations. The absence of the additional exercise meant that the facility did not fully comply with the regulatory requirements for emergency preparedness testing. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the deficiency had not been addressed. The document review during this revisit showed that the facility still had not performed the additional required exercise within the previous 12 months. The Administrator and the Regional Maintenance Director confirmed this ongoing deficiency during an exit interview on the same day.
Plan Of Correction
1. Deficiency: Based on document review and interview, it was determined that the facility failed to conduct one of the two required annual exercises to test the facility's emergency preparedness plan, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed that within the previous 12 months, the facility performed only a full-scale exercise and did not perform the additional required exercise to test the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of the additional exercise. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's emergency preparedness plan is not properly tested through regular exercises. 2. Corrective Action: The facility will conduct the additional required annual exercise, ensuring that both a full-scale exercise and a tabletop exercise (or another approved exercise) are completed within the required time frame to properly test the emergency preparedness plan. A schedule will be developed to ensure that future exercises are performed on time and documented accordingly. 3. Monitoring: The facility will track the completion of required exercises and ensure they are conducted annually as per regulations. Documentation of each exercise, including participant involvement and outcomes, will be reviewed by the Quality Assessment and Assurance Committee. 4. Timeline: The additional required exercise will be completed by 01/28/25. Future exercises will be scheduled and conducted annually, with documentation reviewed for compliance.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10 standards, affecting the entire facility. During a document review on November 20, 2024, the facility was unable to provide certification for the inspector who conducted the annual inspection of the portable fire extinguishers. Additionally, an observation on the same day revealed that a portable fire extinguisher on the first floor, next to resident room 125, was obstructed by wheelchairs. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up revisit on January 8, 2025, showed that the facility still could not produce the required certification for the inspector, as confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K355: Portable Fire Extinguishers 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility. Findings include: Document review on November 20, 2024, at 8:00 a.m., revealed the facility could not produce the certification for the inspector conducting the annual portable fire extinguisher inspection. Observation on November 20, 2024, at 10:42 a.m., revealed that on the first floor, the portable fire extinguisher next to resident room 125 was blocked by wheelchairs. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation and the blocked fire extinguisher. Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected in the event of a fire emergency if fire extinguishers are not properly maintained or accessible. 2. Corrective Action: 1. The certificate for the inspector conducting the annual portable fire extinguisher inspection was obtained and filed on 01/08/25. 2. The portable fire extinguisher located next to resident room 125 was immediately cleared of all wheelchairs and is now accessible. 3. Monitoring: The Maintenance Director will review the portable fire extinguisher inspection records to ensure that certifications are maintained properly. Monthly inspections will be conducted to ensure all fire extinguishers are accessible and not blocked by any items, with audits documented. 4. Timeline: The certificate for the fire extinguisher inspector was obtained and filed on 01/08/25. The wheelchairs were removed, and the fire extinguisher is now accessible as of 11/20/24. Ongoing monthly checks will be conducted to ensure compliance.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders for medications were followed for one resident. Specifically, the facility did not adhere to the prescribed parameters for administering Metoprolol Succinate Extended Release to a resident with Chronic Systolic Heart Failure and Paroxysmal Atrial Fibrillation. The physician's order required the medication to be held if the resident's systolic blood pressure was below 105 mmHg or if the heart rate was less than 60 beats per minute. Upon review of the Medication Administration Record for October 2024, it was found that Metoprolol was administered 23 times when the resident's heart rate was below 60 beats per minute. This was confirmed through an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged that the staff did not follow the physician-ordered parameters for the medication administration.
Failure to Address Significant Weight Change
Penalty
Summary
The facility failed to timely and appropriately address a significant weight change for Resident 93, who was receiving continuous enteral feeding via a gastrotomy tube. The resident experienced a significant weight loss of 9.8 pounds, or 7.54%, in less than a month, dropping from a baseline weight of 130 pounds to 120.2 pounds. Despite the facility's policy requiring re-weighing and timely intervention by the dietitian and interdisciplinary team, the resident was not re-weighed after the weight change was identified on October 16, 2024. Furthermore, the dietitian did not address the significant weight change until October 23, 2024, seven days after it was first identified. The facility's policy also mandates notifying the resident's physician and responsible party of any significant weight changes. However, the physician was not informed of the weight loss until November 1, 2024, two weeks after the significant weight change was identified. The Director of Nursing (DON) reported that re-weighing should occur immediately after a weight change is identified and that nursing staff are responsible for notifying the physician. The DON was informed of the weight loss by the dietitian on October 30, 2024. This delay in addressing the weight change and notifying the physician constitutes a failure to comply with the facility's policy and regulatory requirements.
Failure to Act on Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication irregularities identified during the monthly drug regimen review were acted upon by a physician for one resident. The resident, who was admitted to the facility with a severely impaired cognition as indicated by a BIMS score of 5, had multiple medical diagnoses including restlessness, agitation, unspecified dementia with behavioral disturbance, cognitive communication deficit, Alzheimer's disease, unspecified protein calorie malnutrition, and nutritional deficiency. The resident had physician orders for Mirtazapine for appetite, Lorazepam for anxiety, and Quetiapine for insomnia. Despite the pharmacist's recommendations during the medication record reviews conducted in July, August, and September 2024, which included evaluating the use of Mirtazapine for appetite without a depression diagnosis and the use of Quetiapine for insomnia, the physician merely signed the pharmacy recommendation reports without any response or indication that the recommendations were acted upon. This inaction was confirmed by the Director of Nursing during an interview, highlighting a deficiency in the facility's process for addressing medication irregularities.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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