Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westminster Woods At Huntingdo during CMS and state inspections, most recent first.
Failure to Investigate Repeated Choking Incidents: A resident with cognitive impairment, a mechanically altered diet, and partial feeding assistance needs experienced multiple choking episodes while being fed, including one requiring ER transfer, one requiring the Heimlich maneuver, and one requiring back blows. The record showed no documented investigation for these incidents, and the DON and NHA stated they did not conduct one despite the facility policy requiring thorough investigation of abuse and neglect-related events.
Failure to follow physician orders affected multiple residents. One resident’s ordered nutritional supplement intake was not documented, another resident’s high blood glucose readings were not reported to the MD as ordered, a third resident received amlodipine despite SBP readings below the hold parameter, and an LPN administered a COPD inhaler without requiring the resident to rinse and spit as ordered.
A resident was found lethargic, diaphoretic, mumbling, unable to answer questions appropriately, and with fixed, non-reactive pupils, then sent to the ER for evaluation. The facility did not notify the resident's representative in writing about the hospital transfer and did not provide a bed-hold notice to the responsible party, and the NHA confirmed these omissions.
The facility failed to notify the physician of significant weight changes for two residents. One resident with severe cognitive impairment and malnutrition had repeated large weight losses, but there was no documented reweigh within 24 hours or notification to the charge nurse, MD, or RD. Another resident with kidney failure and heart failure had a rapid weight gain above the ordered threshold, but there was no documented physician notification. The DON confirmed the missing notifications.
A resident with PTSD, anxiety, depression, and traumatic brain injury was not assessed for specific trauma triggers or given documented trauma-informed measures to reduce re-traumatization. The MDS showed the resident was cognitively intact and dependent on staff for daily care needs, but the care plan did not include trigger identification. The SW confirmed no PTSD trigger assessment was completed because the old computer system did not have the assessment program.
A facility failed to ensure accountability of a resident’s controlled pain medication. The resident was cognitively intact, needed staff help with all daily care, and had an order for PRN oxycodone for pain; however, the controlled drug record showed the narcotic was signed out multiple times while the MAR had no documentation that it was administered. The DON confirmed the missing documentation in the resident’s clinical record.
A cognitively intact, fully care-dependent resident with vascular ALS, bowel and bladder incontinence, and multiple skin issues alleged that he had not been changed for several hours. Staff later found his brief and bedding saturated with urine and a bowel movement present, and his call bell placed out of reach at the top of the bed. An RN assessment documented non-blanchable and blanchable areas on the thigh and open excoriations on the abdominal fold and groin. Investigation revealed that the assigned CNA did not provide care because the resident had not used the call bell, and the facility substantiated neglect based on this failure to provide necessary incontinence care.
The facility was found to have multiple deficiencies in food safety and staff hygiene. An opened box of frozen fish fillets was improperly stored, and a deep fryer was not cleaned after use, violating the facility's policies. Additionally, a staff member with a full beard was observed without a beard restraint during food preparation, contrary to the dress code guidelines.
The facility failed to notify a resident's responsible party about a downgrade in diet consistency after a choking incident and did not inform a urologist about UTI symptoms in another resident. Both residents were cognitively intact, and the deficiencies were confirmed by the DON.
A facility failed to develop a care plan for a resident requiring treatment for an infection using a PICC line for IV antibiotics. The resident was admitted for further care of a left heel wound and had orders to receive Ertapenem daily through the PICC line. However, no care plan was documented for the PICC line, infection, or IV antibiotics, as confirmed by the Nursing Home Administrator.
A facility failed to follow physician's orders for a resident with heart failure and high blood pressure. The resident's care plan required specific administration of Carvedilol and Lisinopril based on apical pulse readings. On several occasions, the facility either administered Carvedilol without checking the pulse or withheld Lisinopril against the orders. The DON confirmed these discrepancies.
A facility failed to provide a privacy cover for a resident's indwelling urinary catheter, as required by policy. The resident, who had a neurogenic bladder, was observed with an uncovered catheter collection bag, and the nurse aide confirmed the absence of a privacy bag. The Director of Nursing acknowledged the catheter tubing should not have been in contact with the fall mat.
A resident's medication, specifically 25 mg of Seroquel, was found on the floor in her bathroom, contrary to the facility's policy that medications should be stored in designated areas. The resident, who was cognitively intact and required assistance for daily care needs, was scheduled to receive the medication in the evening. An LPN confirmed the medication should not have been on the floor, and the DON acknowledged the error, indicating a failure in medication storage practices.
The facility failed to ensure that residents were offered and/or received necessary vaccinations. A resident did not receive the pneumococcal vaccine despite consenting, and two residents did not receive the influenza vaccine, with one not being documented as offered the vaccine. These issues were confirmed through staff interviews and record reviews.
A resident with severe cognitive impairment and vascular dementia was subjected to sexual abuse by a maintenance worker, who was observed by two nurse aides straddling, hugging, and rubbing the resident's flank area under her shirt. The incident was documented by staff and confirmed through interviews, indicating a failure to uphold the facility's abuse prevention policy.
A resident with severe cognitive impairment was recorded on a staff member's personal cell phone without consent during an incident where a maintenance worker was observed hugging and touching the resident under her shirt. The recording was made by a nurse aide who witnessed the event and believed it was necessary to document the situation. Facility policy prohibits the use of personal cell phones and requires protection of resident privacy and rights.
A resident with cognitive impairment and a history of stroke experienced a fall and subsequent changes in condition, but the required nursing assessments were not documented in the clinical record. The Director of Nursing confirmed the assessments were completed but not recorded, violating federal and state regulations for maintaining complete and accurate medical records.
A resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Neurological checks were initiated, and the resident was later admitted to the hospital with a stroke diagnosis. The facility failed to notify the Department of Health about this incident until contacted by Adult Protective Services.
A facility failed to create a comprehensive care plan for a resident with frequent UTIs, despite physician's orders for various medications and treatments. The resident's MDS assessment indicated frequent urinary incontinence, but no care plan was documented to address their condition, as confirmed by the DON.
The facility did not complete monthly pharmacy medication reviews for two residents, as required by their policy. The policy requires timely communication of pharmacist recommendations and a response before the next review. For two residents, there was no evidence that the December and January reviews were addressed by the physician. The DON confirmed the lack of documentation during an interview.
A facility failed to protect a resident's health information during medication administration. An LPN left a computer screen displaying a resident's personal health information unsecured and visible in the hallway. Both the LPN and the DON confirmed that the information should have been covered.
A resident with chronic kidney disease and hypertension had an elevated blood pressure reading of 197/86 mm/Hg, which was not reassessed as required by professional standards. Nursing staff confirmed that such a reading should have prompted further evaluation and documentation, but this did not occur.
A resident, who is cognitively impaired and requires moderate assistance, was transported in a wheelchair without leg rests by an RN. The RN acknowledged knowing the requirement to use leg rests, and the DON confirmed that all staff should use them during transport.
A facility failed to document the rationale for the long-term use of Zyprexa for a resident with severe cognitive impairment and diagnoses of depression and dementia. Despite federal regulations requiring as-needed orders for psychotropic drugs to be limited to 14 days, the resident continued to receive Zyprexa without documented justification. The Director of Nursing confirmed the absence of necessary documentation from the attending physician or psychiatric consultant.
The facility failed to secure a medication cart and properly label medications. An LPN left a medication cart unlocked and unattended, and controlled medications were not stored in a permanently-affixed compartment. Additionally, medications like Tubersol and Insulin Lispro were not labeled with the date they were opened, as confirmed by nursing staff.
The facility failed to prevent the elopement of two residents identified as at risk for elopement. One resident exited through the front door due to a receptionist's unawareness, and another resident exited during a fire alarm when door magnets were deactivated. Both residents were found outside and brought back without injuries.
Failure to Investigate Repeated Choking Incidents
Penalty
Summary
The facility failed to complete a thorough investigation for multiple choking incidents involving one resident who was cognitively impaired, required a mechanically altered diet, was dependent on staff for daily care needs, and required partial assistance while eating. The resident’s care plan stated that she was to be fed at assist table when her spouse was not feeding her. Clinical records documented that she choked on vomit after dinner and required a nurse aide to remove mucus and vomit from her mouth before transfer to the emergency room, that she later could not clear her throat while being fed and required the Heimlich maneuver to open her airway and expel food, and that she again choked while being fed in the dining room and required back blows until the food was coughed out. A review of the clinical record found no documented evidence that an investigation was completed for these choking incidents. During interview, the DON and NHA stated that there was information in a nursing note and that they did not do an investigation into the incidents. The facility policy for abuse and neglect stated that events involving abuse, neglect, and related concerns shall be thoroughly investigated, including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 hours or within the identified timeframe.
Failure to Follow Physician Orders for Medications, Monitoring, and Treatment
Penalty
Summary
The facility failed to follow physician’s orders for four residents. One resident had severe cognitive impairment, required supervision or touching assistance for eating, had unexpected weight loss, and diagnoses including malnutrition; the resident was ordered to receive a magic cup twice daily for weight loss, with documentation of the amount consumed, but the Medication Administration Record did not document how much was eaten. The Director of Nursing confirmed there was no documentation of the amount consumed. Another resident had diabetes and received insulin injections; the physician ordered staff to notify the physician if blood glucose was below 70 mg/dL or above 350 mg/dL, but blood sugars of 376, 357, 373, 380, and 401 mg/dL were recorded without documented evidence that the physician was notified. A third resident with dementia and heart disease was ordered to receive amlodipine 2.5 mg daily, held if systolic blood pressure was less than 140 mmHg, yet the medication was administered on multiple occasions when systolic blood pressure readings were 139, 121, 126, and 117 mmHg. A fourth resident with COPD was ordered to receive Trelegy Ellipta once daily and to rinse and spit after use, but an LPN administered the inhaler without having the resident rinse and spit, and the DON confirmed the order was not followed.
Failure to Notify Representative of Hospital Transfer and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to notify the resident's representative in writing of the reason for transfer to the hospital and failed to provide a bed-hold notice to the resident's responsible party for Resident 23. A nursing note dated February 6, 2026, documented that Resident 23 was found lethargic, mumbling, diaphoretic, unable to answer questions appropriately, and with pupils that were non-reactive and fixed, after which she was sent to the emergency room for evaluation. Review of the clinical record found no documented evidence that the resident representative was notified in writing of the hospital transfer, and no bed-hold notice was provided at the time of transfer. The Nursing Home Administrator stated in interview that she did not notify the resident's representative of the hospital transfer and that the bed-hold notice was not provided.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that the physician was notified of significant weight changes for two residents. A facility policy dated December 29, 2025 required that weight variances of plus or minus five pounds or more for residents over 100 pounds be reweighed within 24 hours and reported by the charge nurse to the physician, dietitian, and responsible party. Resident 1 had severe cognitive impairment, required supervision or touching assistance for eating, had diagnoses including malnutrition, and had a nutritional care plan for monitoring weights and meal intake. The record showed a 10.8-pound weight loss in one week in November 2025 and an 11.2-pound weight loss in one week in December 2025, but there was no documented evidence that the resident was reweighed within 24 hours or that the charge nurse, physician, or dietitian was notified of either weight loss. Resident 22 had diagnoses including kidney failure and heart failure, was cognitively intact, and had a care plan noting risk for weight fluctuations due to diuretic use. A physician order required weekly weights and notification if the resident gained 3 pounds in 24 hours or 5 pounds in a week. The weight record showed an increase from 229 pounds to 236.4 pounds in three days, a gain of 7.4 pounds, but there was no documented evidence that the physician was notified. The DON confirmed in interview that there was no documented evidence of notification and that the physician should have been notified.
Failure to Assess PTSD Triggers
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including depression, anxiety, PTSD, and traumatic brain injury was assessed for trauma-informed care needs and specific PTSD triggers. A Quarterly MDS assessment dated April 4, 2026, showed the resident was cognitively intact and dependent on staff for daily care needs, and the care plan dated July 16, 2025, documented PTSD, anxiety, and traumatic brain injury. However, there was no documented evidence that the facility identified the resident’s specific triggers that could re-traumatize the resident or that it implemented measures for staff to prevent or minimize those triggers. During an interview on May 6, 2026, the Social Worker confirmed that no PTSD trigger assessment was completed and stated it was not done because the old computer system did not have the assessment program.
Controlled Medication Not Accounted for in MAR
Penalty
Summary
The facility failed to ensure accountability of controlled medications for one resident who was cognitively intact, required staff assistance for all daily care needs, and was receiving opioid medication. The resident’s care plan indicated she would display pain by yelling out and that nursing was to assess pain and administer pain medications as ordered. Physician orders included oxycodone 5 mg every four hours as needed for pain. Review of the resident’s controlled drug record showed oxycodone was signed out on multiple occasions in February and April 2026, but there was no documented evidence in the MAR that the medication was administered on those dates and times. The DON confirmed during interview that there was no documented evidence in the resident’s clinical record that the oxycodone was administered on those occasions and that there should have been.
Failure to Provide Timely Incontinence Care and Maintain Call Bell Access
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from neglect when assigned care was not provided over an extended period. The resident, who was dependent on staff for daily care, incontinent of bowel and bladder, and diagnosed with vascular ALS, alleged that he had not received proper care and had not been changed for about six hours. A quarterly MDS indicated that the resident was able to understand and be understood, but required staff for all daily care needs. On the evening in question, the resident reported to a nurse aide that he had been lying in bed for six hours without assistance. A subsequent RN assessment documented that the resident’s incontinence brief and bedding were saturated and that his call bell was not within reach, being located at the top of the bed. The assessment also identified multiple skin issues, including a non-blanchable purple area and a blanchable red area on the left thigh, and open excoriated areas on the abdominal fold and right groin. Investigation interviews confirmed that the assigned nurse aide did not provide care because the resident had not used the call bell, despite his dependence on staff for care. Other staff reported finding the resident with urine-saturated linens and a bowel movement present before providing incontinence care and changing all bedding. The facility’s investigation concluded that the allegation of neglect was substantiated based on the nurse aide’s failure to provide care.
Deficiencies in Food Safety and Staff Hygiene
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and staff hygiene. During an inspection, it was observed that an opened box of frozen fish fillets was left exposed to the air in the kitchen's walk-in freezer, contrary to the facility's policy requiring bulk freezer items to be properly sealed. This was confirmed by the Dietary Director, who acknowledged that the fish fillets should have been covered. Additionally, the deep fryer in the meal preparation area was found to have a large amount of floating fried debris, indicating it had not been cleaned after use, which is a violation of the facility's policy on sanitizing equipment to prevent food-borne illness. Furthermore, the facility's dress code guidelines were not followed, as observed during a tray line service where a staff member with a full beard and mustache was not wearing a beard restraint while preparing drinks and trays. This was in direct violation of the facility's policy that requires facial hair restraints for staff involved in food production. The Dietary Director confirmed that staff were expected to wear appropriate hair restraints, highlighting a lapse in enforcing hygiene standards during food preparation.
Failure to Notify Responsible Parties and Urologist of Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about changes in diet consistencies and failed to inform a urologist about symptoms of a urinary tract infection (UTI) for two residents. Resident 10, who was cognitively intact and dependent on staff for care needs, experienced a choking incident on water during medication administration. As a result, the resident's diet was downgraded from thin liquids to nectar thick liquids. Despite this significant change, there was no documented evidence that the resident's responsible party was informed about the downgrade in diet consistency after the incident or following a speech therapy assessment. Resident 22, who was also cognitively intact and had an indwelling urinary catheter, was under a urology consult that required notification of the urologist if UTI symptoms developed. The resident exhibited symptoms such as lower back pain and urinary frequency, leading to the reinsertion of the foley catheter. However, there was no documented evidence that the urologist was notified about these symptoms. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure in communication and notification protocols.
Failure to Develop Care Plan for PICC Line and IV Antibiotics
Penalty
Summary
The facility failed to develop a care plan for a resident who required treatment for an infection using a Peripherally Inserted Central Line (PICC) for intravenous antibiotics. The resident was admitted from the hospital for further care of a left heel wound and had physician's orders to receive 1 gram of Ertapenem daily through the PICC line. However, there was no documented evidence in the resident's clinical record indicating that a care plan was developed for the care and treatment of the PICC line, infection, or IV antibiotics. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident with heart failure and high blood pressure, identified as Resident 16. The resident's care plan included specific instructions for administering Carvedilol and Lisinopril based on the resident's apical pulse. On multiple occasions in January, February, and March 2025, the facility did not adhere to these orders. Specifically, on January 6, 2025, Carvedilol was administered without obtaining the required apical pulse, which should have been held if the pulse was below 50 bpm. Additionally, Lisinopril was inappropriately withheld on January 22 and 30, and February 13 and 23, 2025, despite orders to administer it daily. On March 23, 2025, Carvedilol was withheld when the resident's apical pulse was 71 bpm, contrary to the physician's orders. The Director of Nursing confirmed these discrepancies during an interview on April 3, 2025.
Failure to Provide Privacy Cover for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide a privacy cover for a resident with an indwelling urinary catheter, as required by their policy. The policy, dated January 22, 2025, mandates that indwelling urinary catheters must be covered and placed below the bladder for proper drainage. The resident, who was cognitively intact, had an indwelling urinary catheter due to neurogenic bladder, a condition causing loss of bladder control. Observations on March 31, 2025, revealed that the resident's catheter collection bag was uncovered, and urine was visible while being transported by a nurse aide. The nurse aide confirmed the absence of a privacy bag and mentioned searching for one since the morning. The Director of Nursing also confirmed that the catheter tubing should not have been in contact with the fall mat. This deficiency was identified during a review of facility policies, clinical records, observations, and staff interviews, highlighting a failure to adhere to the facility's catheter care policy.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medication appropriately for one of the residents, identified as Resident 23. According to the facility's policy on medication storage, medications for internal use should be stored in medication carts or other designated areas. However, during an observation and interview with Resident 23, a round pink/orange pill was found on the floor in her bathroom. The resident, who was cognitively intact and required assistance for daily care needs, was receiving antipsychotic medication, specifically 25 mg of Seroquel daily for psychosis. The pill on the floor was identified as Seroquel, which the resident was scheduled to receive in the evening. Licensed Practical Nurse 2 confirmed that the medication should not have been on the floor and explained that Resident 23 was the only one using that toilet, and her morning medications were crushed and served with pudding or applesauce. The Director of Nursing also confirmed that medication should not be on the floor, indicating a failure in adhering to the facility's medication storage policy. This incident highlights a deficiency in the facility's handling and storage of medications, as outlined by the relevant state codes.
Failure to Administer Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and/or received necessary vaccinations, specifically the pneumococcal and influenza vaccines. Resident 5, who was cognitively intact, had consented to receive the pneumococcal vaccine as indicated by a signed authorization form dated November 19, 2024. However, the resident did not receive the vaccine, which was confirmed by the Registered Nurse Assessment Coordinator. Similarly, Resident 11, also cognitively intact, had consented to receive the influenza vaccine as per a consent form dated October 2, 2024, but did not receive it, as confirmed by the Director of Nursing. Additionally, Resident 14, who was cognitively intact and dependent on staff for daily care, was not documented as having been offered the influenza vaccine for the 2024-2025 flu season. The Director of Nursing confirmed the absence of documentation indicating that the resident was offered the vaccine. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews, highlighting a failure in the facility's vaccination procedures.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a maintenance worker and a resident with severe cognitive impairment and vascular dementia. The resident, who was rarely understood and sometimes able to understand others, was observed by two nurse aides to be inappropriately touched by the maintenance worker. Specifically, the maintenance worker was seen straddling the resident while she was seated in her recliner, hugging her, and rubbing her flank area under her shirt. One of the nurse aides recorded a video of the incident on her personal cell phone to document the behavior, as she believed it might not be believed otherwise. Interview statements from the involved staff confirmed the observations, with one aide stating that the maintenance worker's hand was under the resident's shirt and that he was rubbing her side. The maintenance worker admitted to hugging the resident but could not recall if his hand was under her shirt. The incident was witnessed by two nurse aides, who corroborated each other's accounts. The facility's abuse policy required that residents be protected from all forms of abuse, including sexual abuse, but this policy was not upheld in this instance.
Resident Recorded Without Consent During Incident Involving Staff
Penalty
Summary
The facility failed to ensure that residents were protected from being recorded on a personal cell phone without their permission. Facility policy stated that residents should be provided with a safe environment free from abuse, mistreatment, neglect, exploitation, and misappropriation of property. In this incident, a resident with severe cognitive impairment and vascular dementia, who was rarely understood and sometimes able to understand others, was involved. Maintenance staff was observed by two nurse aides to be straddling the resident while she was seated, hugging her, and rubbing her flank area under her shirt. One of the nurse aides, after observing this behavior, used her personal cell phone to record a video of the interaction without the resident's consent. Interview statements revealed that the nurse aide recorded the video because she believed the situation was unusual and wanted evidence of what she witnessed. The resident's face was not visible in the video, and the resident could not be identified. The Nursing Home Administrator confirmed that staff were not permitted to use personal cell phones during working hours and acknowledged that the nurse aide was aware she should not have recorded the video. The incident was determined to be a failure to protect the resident's rights and privacy as outlined in facility policy and state regulations.
Incomplete Documentation of Resident Assessments
Penalty
Summary
Westminster Woods at Huntingdon was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. The facility failed to ensure that clinical records were complete and accurately documented for a resident who was cognitively impaired and had a history of stroke. On January 18, 2025, the resident was found on the floor, and although neurological checks were ordered, there was no documented evidence of registered nurse assessments at critical times when the resident's condition changed, such as when the resident complained of a dry mouth, had issues answering questions, and could no longer raise her arm. The facility's policy required documentation of all assessments and interventions following an incident, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the assessments were completed but not documented in the clinical record, which was a requirement. This lack of documentation was a violation of both federal regulations under 42 CFR Part 483 and state regulations under 28 PA Code, which mandate that medical records be complete, accurately documented, and systematically organized.
Plan Of Correction
Resident 1 Electronic Medical Record was updated to reflect nurse assessments in the clinical record. A review of current residents reported change in conditions that occurred in the last 30 days will be completed to ensure there is a documented nurse assessment in the clinical record. Education provided by Director of Nursing to current licensed staff the process to record nurse assessment in medical record after evaluation. Director of Nursing or designee will audit 3 random resident records for change in condition x 4wks, then 3 random records monthly for documentation of nursing assessment when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for serious harm. The resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Following this incident, neurological checks were initiated. Later, the resident's daughter requested that the resident be sent to the emergency room for evaluation, and the resident was subsequently admitted to the hospital with a diagnosis of a stroke. Despite these events, there was no documented evidence that the incident was reported to the Department of Health until after Adult Protective Services contacted the facility, confirming the delay in notification.
Plan Of Correction
Resident 1 has had an incident reported to the Department of Health. A review of the last 30 days incidents were audited to find any resident who were sent for treatment to verify they had been reported to the Department of Health. Education provided to Director of Nursing regarding the process to report resident admissions to the hospital when they are due to an incident that occurred in the facility. Nursing Home Administrator or designee will audit 3 random resident incident reports for transfer to hospital x 4 weeks, then 3 random records monthly for documentation of Event Report submitted to the Department of Health when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Develop Comprehensive Care Plan for UTI Management
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident experiencing frequent urinary tract infections (UTIs) and related medication use. The facility's policy, dated March 26, 2024, required that care plans be developed with input from an interdisciplinary team and involve the resident or their representative. However, for one resident, there was no documented evidence of a care plan addressing their frequent UTIs and the use of medications prescribed for prevention and treatment. The resident's quarterly Minimum Data Set (MDS) assessment indicated they were frequently incontinent of urine and occasionally incontinent of bowel. Physician's orders included various medications and treatments for UTI prevention and treatment, such as D-mannose, Estradiol cream, and Macrobid. Despite these orders, the facility did not create a care plan to manage the resident's condition, as confirmed by the Director of Nursing during an interview.
Failure to Complete Monthly Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication reviews were completed for two residents, as required by their policy. The policy, dated March 26, 2024, mandates that comments and recommendations from the consultant pharmacist regarding medication therapy be communicated in a timely manner, allowing for a response before the next review. If the prescriber does not respond within 30 days, the Director of Nursing or the consultant pharmacist should contact the Medical Director. However, for Residents 3 and 14, there was no documented evidence that the monthly medication reviews for December 2023 and January 2024 were addressed by the physician or designee. An interview with the Director of Nursing on May 16, 2024, confirmed the absence of documentation indicating that the medical provider addressed the medication reviews for these months. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding pharmacy services.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On May 14, 2024, a Licensed Practical Nurse (LPN) left the medication cart unattended twice without securing the computer screen, which displayed Resident 48's personal health information. The screen was facing the hallway, making the information visible to passersby. The LPN acknowledged the oversight during an interview, confirming that the information should have been covered. The Director of Nursing also confirmed that the computer screen should have been secured when unattended.
Failure to Reassess Elevated Blood Pressure
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not further assessing an elevated blood pressure for one resident. The resident, who was moderately cognitively impaired and had diagnoses including chronic kidney disease and primary hypertension, was on medication for high blood pressure. On a specific day, the resident's blood pressure was recorded at 197/86 mm/Hg, which is significantly higher than the normal range of 120/80 mm/Hg as determined by the American College of Cardiology and the American Heart Association. Despite the elevated reading, there was no documented evidence that the blood pressure was reassessed. Interviews with nursing staff confirmed that such an elevated reading would typically warrant a recheck, evaluation, and documentation, which did not occur. The Director of Nursing also confirmed that the elevated blood pressure warranted further assessment, which was not performed.
Failure to Use Leg Rests During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment for residents by not using leg rests while transporting a resident in a wheelchair. Resident 47, who is cognitively impaired and requires moderate assistance for all care, was observed being pushed in a wheelchair without leg or foot rests by Registered Nurse 4. This occurred as the resident was moved from her room to the dining room, with her feet elevated due to the absence of leg rests. Registered Nurse 4 acknowledged awareness of the requirement to use leg rests during transport. The Director of Nursing confirmed that all staff, including agency and hospice staff, are expected to use leg/footrests when transporting residents in wheelchairs.
Failure to Document Rationale for Long-term Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of psychotropic drugs. The facility policy and federal regulations require that as-needed orders for psychotropic medications be limited to 14 days unless a documented rationale is provided for extending the order. In the case of Resident 14, who was severely cognitively impaired with diagnoses of depression and dementia, there was an order for a 5 mg injection of Zyprexa to be administered daily as needed for combativeness. However, there was no documented evidence that this order was discontinued after 14 days, nor was there any documented rationale for its long-term use. The clinical records, including physician progress notes and consultant pharmacist recommendations, lacked any justification for the continued as-needed use of Zyprexa for Resident 14. The Director of Nursing confirmed that there was no documented rationale provided by the attending physician or a psychiatric consultant for the long-term use of this medication. This oversight indicates a failure to adhere to both facility policy and federal regulations, resulting in the resident receiving potentially unnecessary medication without proper documentation or justification.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper security and labeling of medications, as observed during a survey. A medication cart was found unlocked and unattended by an LPN while administering medications to a resident, which was confirmed by both the LPN and the Director of Nursing. Additionally, controlled medications were not stored in a separately locked, permanently-affixed compartment within the medication refrigerator, as required. This was confirmed by both a registered nurse and the Assistant Director of Nursing. Furthermore, the facility did not label medications with the date they were opened, as required by their policy. An opened vial of Tubersol in the main medication room refrigerator and an Insulin Lispro pen in a medication cart were not properly labeled with the date they were opened. These deficiencies were confirmed by interviews with nursing staff, including a registered nurse and the Assistant Director of Nursing.
Failure to Prevent Elopement of At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent elopement for two residents identified as at risk for elopement. Resident 1, who had a diagnosis of altered mental status and was new to the facility, was identified as an elopement risk upon admission. Despite being equipped with a Wanderguard device, Resident 1 managed to exit the facility through the front door, which was opened by a receptionist who was unaware of the resident's status. The receptionist did not hear any alarms, and the resident was later found outside and brought back into the facility without injuries. Resident 2, who had a diagnosis of dementia and was also identified as an elopement risk, managed to exit the facility during a fire alarm. The fire alarm system deactivated the door magnets, allowing the resident to walk out. The resident was found outside knocking on the door to be let back in. The Wanderguard system did not function properly during the fire alarm, and the resident was promptly assisted back inside without injuries. Interviews with staff revealed that the receptionist was not familiar with Resident 1 and did not receive a photo of him in time. Additionally, the fire alarm system's deactivation of door magnets during emergencies allowed Resident 2 to exit the building. Both incidents highlighted lapses in the facility's supervision and intervention measures to prevent elopement, despite the presence of Wanderguard devices and other security measures.
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Illustrative
What surveyors actually found near you
We read the 225 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntingdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Huntingdon Park | 1.5 mi | ★★★★★ | 23 | 0 |
| Cedarwood Rehabilitation & Healthcare Center | 16.1 mi | ★★★★★ | 17 | 0 |
| Valley View Haven, Inc | 17.5 mi | ★★★★★ | 5 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 19.2 mi | ★★★★★ | 3 | 0 |
| Embassy Of Hearthside | 19.8 mi | ★★★★★ | 43 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.