Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Westgate Hills Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
Improper Food Storage and Labeling in Main Kitchen: Surveyors observed food items stored on the floor in dry storage, including crackers, syrup, a used glove, and Glucerna Shakes, along with open or unsealed food items in the freezer, refrigerator, and prep refrigerator that were missing proper dates and labels. The Kitchen Manager confirmed open bags and containers should have been sealed and labeled with a used-by date, and the NHA acknowledged the improper storage and sanitation issues.
A resident with significant mobility and dressing needs remained in a hospital gown for hours while waiting for staff to help change into chosen clothing, and the DON and NHA confirmed nursing staff should have assisted. Another resident with gait, coordination, and weakness issues was observed being fed by a nurse aide who stood over the resident during meals, and later the resident was seen trying to eat in bed with food and coffee spilled on the tray and gown; OT records showed the resident needed assistance with scooping food and hand-to-mouth feeding.
A resident with nutritional deficiency and Huntington’s disease had a physician order for continuous PEG tube feeding of Jevity 1.5 until a total of 1300 mL was infused. MAR review showed multiple entries with volumes below the ordered amount or no amount recorded, and the DON confirmed the tube feeding order was not being documented correctly.
Missing Physician Orders for Respiratory Care: A resident with intracerebral hemorrhage, acute respiratory failure with hypoxia, and tracheostomy status had no physician orders for oxygen therapy, including route, flow rate, or frequency. The care plan contained incomplete oxygen settings, and the resident was observed receiving oxygen via tracheostomy tubing with the concentrator set at 6 lpm and the pressure pump at level 5; the DON stated the resident did not have physician orders for oxygen care because the resident was on room oxygen.
A resident with ESRD and dependence on hemodialysis had an ordered daily fluid restriction divided between dietary and nursing, but the MAR did not show the amount of fluid received each shift. The facility policy required verification and documentation of the fluid restriction breakdown in the medical record, and an employee confirmed the missing documentation.
Medication Cart Storage and Labeling Deficiency: The facility failed to properly label and secure medications on 2 of 3 med carts reviewed. Surveyors found open eye drops that were undated or dated beyond the facility's policy on the 2nd floor back hall cart, and the 1st floor back hall cart was observed unlocked and unattended in the hallway. An LNE confirmed the cart was assigned to her and that the medications were unsecure.
A resident with stroke-related aphasia, dysphagia, and a feeding tube was ordered ST 4-5 times per week and had a care plan for skilled ST to improve swallowing function and diet tolerance. Records showed therapy was provided after the initial eval and then not again until much later, and the DOR stated a missed session occurred because the resident was at a holiday event and the therapist did not want to interrupt, while the facility was using a part-time SLP because the full-time SLP was on planned leave.
Inaccurate MAR Documentation for Refused Lidocaine Patch: A resident with stroke-related hemiplegia and difficulty walking had an active order for a lidocaine 4% patch to the right shoulder for pain. The MAR documented the patch as administered, but the resident stated she refused it because she was not in pain, and observation confirmed no patch was in place. The NHA and DON confirmed staff inaccurately recorded the medication as given despite the refusal.
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.
Improper Food Storage and Labeling in Main Kitchen
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions and failed to properly label and date food products in the Main Kitchen. During an observation of the main kitchen, surveyors found three packets of crackers, one maple syrup container, one used rubber glove, and one box containing 24 Glucerna Shakes on the floor in dry storage, along with one open bag of pasta that lacked proper dating and labeling. In the walk-in freezer, one open bag of chicken patties was not sealed and was missing an appropriate date and label. In the walk-in refrigerator, two open bags of bread were missing a used-by date and label, and in the prep refrigerator, one bag of sliced cheese was missing an appropriate date and label. The Kitchen Manager confirmed that open bags and containers should have been properly sealed and labeled with a used-by date, and the NHA confirmed the facility failed to properly store food, maintain sanitary conditions, and properly label and date food products in the main kitchen.
Failure to Preserve Resident Dignity During Dressing and Eating Assistance
Penalty
Summary
The facility failed to protect residents’ rights to dignity and respect for two residents. One resident with a history of stroke, hemiplegia and hemiparesis, muscle wasting, and difficulty walking was assessed as needing assistance with dressing. During an interview, the resident was waiting for staff to help change out of a hospital gown into clothing the resident had selected. Observations later that day showed the resident remained in the hospital gown for several hours while waiting for assistance. The DON and NHA confirmed that nursing staff should have assisted the resident in changing into appropriate personal clothing. Another resident with diagnoses including lack of coordination, gait and mobility abnormalities, muscle wasting and weakness, and lumbar intervertebral disc degeneration was assessed as needing set-up or clean-up assistance with eating. The care plan stated the resident fed self independently with set-up assist as needed, and OT discharge documentation showed the resident required assistance with scooping food and hand-to-mouth feeding. Despite this, observations showed a nurse aide feeding the resident breakfast and lunch while standing over the resident, and later the resident was observed attempting to eat in bed with oatmeal and coffee spilled on the tray, bed table, and gown, while trying to drink from a lidded cup that was leaking onto the resident’s chest. The DON stated the aide was standing because of a knee condition.
Tube Feeding Order Not Followed or Documented Correctly
Penalty
Summary
The facility failed to follow a physician order for Resident 11’s enteral nutrition. Resident 11 had diagnoses including nutritional deficiency, unspecified, and Huntington’s disease. A physician order dated October 17, 2025 directed continuous tube feeding of Jevity 1.5 at 65 mL per hour via PEG tube, with the feeding to run until a total volume of 1300 mL had been infused, providing 1950 kcal. Review of the MAR for October and November 2025 showed multiple instances where the documented Jevity 1.5 volume did not match the ordered total volume, including 1000 mL on October 1, no amount recorded on October 8, 900 mL on October 11, 13, and 14, 820 mL on October 15, 839 mL on November 18, and 607 mL on November 25. The DON confirmed in interview that the tube feeding order was not being documented correctly.
Missing Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to develop physician orders regarding respiratory care for one resident with diagnoses including nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, and tracheostomy status. Review of the resident’s clinical record showed that physician orders did not include oxygen therapy instructions such as the method of administration, volume, or frequency, even though the resident had a tracheostomy and required respiratory support. The facility policy on tracheostomy care stated that necessary respiratory care and services, including oxygen therapy, treatments, mechanical ventilation, tracheostomy care, and/or suctioning, would be provided based on the resident’s assessment and attending physician orders. The resident’s care plan included a focus for tracheostomy related to impaired breathing mechanics with an intervention to administer humidified oxygen as prescribed. A separate care plan focus for altered respiratory status/difficulty breathing contained incomplete entries for oxygen settings, including unspecified route, liters, frequency, and humidification. During observation, the resident was receiving oxygen via tracheostomy tubing, with the oxygen concentrator set at 6 lpm and the pressure pump set to level 5. When this information was presented, the DON stated the resident did not have physician orders for oxygen care because the resident was on room oxygen.
Failure to Document Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for one resident with ESRD and dependence on hemodialysis when the facility failed to follow the resident’s ordered fluid restriction. The facility policy titled Fluid Restriction required the nurse, in collaboration with the dietician, to obtain and verify the physician’s fluid restriction order and a breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department, with the information recorded in the medical record. The resident’s physician ordered a daily fluid restriction of 2000 mL/day, with 1000 mL for dietary and 1000 mL for nursing, further divided by meal and shift amounts. Review of the resident’s MAR did not show evidence of the amount of fluid the resident was receiving each shift, and an employee confirmed this finding during interview.
Medication Cart Storage and Labeling Deficiency
Penalty
Summary
The facility failed to label and store medications in accordance with currently accepted professional principles for 2 of 3 medication carts reviewed, specifically the 1st floor back hallway medication cart and the 2nd floor back hallway medication cart. Facility policy titled "Medications with Shortened Expiration Dates" stated that all eye drops must be dated upon opening and discarded 3 months after opening unless they have a shortened expiration date. On the 2nd floor back hall med cart, surveyors observed an open Redness Reliever eye drop bottle that was undated, an open Artificial Tears bottle dated 8/26/2025, and another open Artificial Tears bottle dated 8/31/2025. On the 1st floor back hall medication cart, surveyors observed the cart unlocked and standing in front of a resident's room at the end of the hall. Staff who came out of the room stated they were not the nurse on the unit and would get the nurse, and they went to the nurses' station to call the nurse. An LNE later confirmed that she was assigned to the med cart and that it was unlocked and the medications were unsecure.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The facility failed to provide specialized speech therapy services as required by the comprehensive care plan for Resident 29. The resident was admitted with traumatic hemorrhage of the right cerebrum with loss of consciousness, aphasia, dysphagia, and a feeding tube, and was receiving 100% of nutritional needs through the feeding tube. The care plan dated December 15, 2025 included skilled ST services as ordered for strengthening and PO trials to improve oropharyngeal function and ability to tolerate the least restrictive diet, and the physician order dated the same day directed speech therapy 4-5 times per week. Speech therapy records showed the resident received an SLP evaluation on December 15, 2025 and therapy sessions on December 17, 19, and 21, 2025, but the next documented session was not until December 31, 2025. During interview, the Director of Rehab Services stated the resident should have received therapy on December 24, 2025, but she was attending a holiday event in the facility and the speech therapist did not want to interrupt her activity. The Director of Rehab Services also stated the facility did not have a full-time SLP on staff because the full-time SLP was on planned leave and a part-time SLP from the corporate office was filling in.
Inaccurate MAR Documentation for Refused Lidocaine Patch
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident, R31, by documenting administration of a lidocaine 4% pain relief patch on the MAR even though the resident refused the medication. R31 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle wasting and atrophy at multiple sites, and difficulty walking. The resident had an active order for a lidocaine patch to the right shoulder for pain, to be applied daily for 12 hours on and 12 hours off, with a start date of January 7, 2025. The MAR showed the lidocaine patch as administered at 9:00 a.m., but during an interview later that morning, R31 stated she refused the patch because she was not experiencing pain. Observation of the resident's right shoulder at that time confirmed there was no lidocaine patch in place. The NHA and DON later confirmed that nursing staff inaccurately documented the medication as administered despite the resident's refusal, resulting in an inaccurate medical record that did not correctly reflect the resident's medication administration status.
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.
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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 Havertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quadrangle | 1.8 mi | ★★★★★ | 1 | 0 |
| Rosewood Gardens Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Bryn Mawr Village | 2.6 mi | ★★★★★ | 23 | 0 |
| Broomall Manor | 2.7 mi | ★★★★★ | 1 | 0 |
| Bryn Mawr Extended Care Center | 2.9 mi | ★★★★★ | 30 | 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 July 2026) and official state health department websites.