WESTMINSTER WOODS AT HUNTINGDO
Non profit - Corporation
64 Beds
PRESBYTERIAN SENIOR LIVING
Data: November 2025
Trust Grade
50/100
#512 of 653 in PA
Photo by Westminster Woods
Photo by Westminster Woods
Photo by Westminster Woods
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Westminster Woods at Huntingdon has a Trust Grade of C, which indicates it is average and falls in the middle of the pack compared to other nursing homes. It ranks #512 out of 653 facilities in Pennsylvania, placing it in the bottom half, and is #3 out of 3 in Huntingdon County, meaning there is only one local option that is better. The facility's trend is worsening, with issues increasing from 7 in 2024 to 8 in 2025. Staffing is a relative strength, with a 4/5 star rating and a turnover rate of 44%, which is below the state average. Although there are no fines on record, the facility has faced some concerning incidents, such as failing to properly store food, not completing medication reviews for residents, and not updating care plans for residents at risk of falls. Overall, while there are strengths in staffing and a lack of fines, the facility has significant concerns in care quality and compliance that families should consider.
- Trust Score
- C
- In Pennsylvania
- #512/653
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 22%
No red flags
7 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Pennsylvania average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near Pennsylvania avg (46%)
Typical for the industry
Chain: PRESBYTERIAN SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 25 deficiencies on record
Apr 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about ...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about changes in diet consistencies for one of 34 residents (Resident 10) reviewed and failed to notify the urologist regarding symptoms of a urinary tract infection (UTI) for one of 34 residents (Resident 22).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated March 11, 2025, indicated that the resident was cognitively intact, was dependent on staff for care needs, and had a mechanically altered diet.
A nurse's note for Resident 10, dated October 4, 2024, revealed that the resident was observed choking on water during medication administration and was downgraded from thin liquids to nectar thick as a nursing measure.
A note from speech therapy, dated October 29, 2024, revealed that Resident 10 was safe to ingest nectar thick liquids.
There was no documented evidence that Resident 10's responsible party was notified of the resident's diet consistency downgrade to nectar thickened liquids after the incident on October 4, 2024, and after receiving speech therapy on October 29, 2024.
Interview with the Director of Nursing on April 1, 2025, at 12:48 p.m. confirmed that there was no documented evidence that the resident's responsible party was notified that Resident 10's diet consistency was downgraded.
A significant MDS assessment for Resident 22, dated November 28, 2024, revealed that the resident was cognitively intact, required assistance with daily care tasks, and had an indwelling (foley) urinary catheter.
A urology consult for Resident 22, dated December 12, 2024, revealed that the resident was to have a voiding trial and to notify the urologist if the resident developed any UTI symptoms.
A nursing note for Resident 22, dated December 19, 2024, revealed that the resident was having symptoms of lower back pain, urinary frequency, and that the foley catheter was reinserted.
There was no documented evidence that the urologist was notified regarding the UTI symptoms.
Interview with the Director of Nursing on April 2, 2025, at 12:21 p.m. confirmed that there was no documented evidence in Resident 22's clinical record that the facility called the urologist to notify him about the UTI symptoms.
28 Pa. Code 211.12(d)(1)(3) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop a care plan for a Peripherally Inserted Central Line (PICC) to treat an infectio...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop a care plan for a Peripherally Inserted Central Line (PICC) to treat an infection that required the use of intravenous antibiotics for one of 34 residents reviewed (Resident 66).
Findings include:
According to admission paperwork for Resident 66, dated March 19, 2025, the resident was admitted from the hospital for further care of his left heel wound on March 19, 2025. Physician's orders for Resident 66, dated March 19, 2025, included an order for the resident to receive 1 gram of Ertapenem (antibiotic) once daily through his PICC line.
There was no documented evidence in Resident 66's clinical record to indicate that a care plan was developed for the care and treatment of a PICC line, infection, or IV antibiotics.
Interview with the Nursing Home Administrator on April 2, 2025, at 9:02 a.m. confirmed that a care plan for Resident 66's PICC line, infection, and IV antibiotics was not developed.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident ...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 16).
Findings include:
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 22, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included heart failure and high blood pressure.
Physician's orders for Resident 16, dated August 17, 2024, included orders for the resident to receive 6.5 milligrams (mg) of Carvedilol (treats high blood pressure) once a day, to be held if his apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) is less than 50 beats per minute (bpm), and to administer 5 mg lisinopril (treats high blood pressure) daily.
A review of the January, February, and March 2025 Medication Administration Record (MAR) for Resident 16 revealed the following:
On January 6, 2025, no apical pulse was obtained and the carvedilol dose was administered when it should have been held according to the physician's orders.
On January 22 and 30, 2025, the lisinopril was held, and should have been administered according to physician's orders.
On February 13 and 23, 2025, the lisinopril was held, and should have been administered according to physician's orders.
On March 23, 2025, the resident's apical pulse was 71 bpm, and the carvedilol dose was held when it should have been administered according to the physician's orders.
Interview with the Director of Nursing on April 3, 2025, at 12:47 p.m. confirmed that the carvedilol and lisinopril were not administered to Resident 16 per physician's orders on the dates listed.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a privacy cover was provided for one ...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a privacy cover was provided for one of 34 residents reviewed (Resident 54) who had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine) insertion indicators, dated January 22, 2025, revealed that indwelling urinary catheters must be covered and placed below the bladder for proper drainage.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated March 13, 2025, revealed that the resident was cognitively intact, had an indwelling urinary catheter, and had diagnoses that included obstructive uropathy (normal flow of urine through the urinary tract is blocked) and benign prostatic hyperplasia (BPH - enlarge prostate).
Physician's orders for Resident 54, dated March 7, 2025, included an order for the resident to have an indwelling urinary catheter due to neurogenic bladder (a condition that causes loss of bladder control due to damage to the nervous system), to be changed as needed for dislodgement, blockage, or leakage. A care plan, dated March 27, 2025, indicated that Resident 54 required an indwelling urinary catheter related to a neurogenic bladder.
Observations of Resident 54 on March 31, 2025, at 11:17 a.m. revealed that the resident was in his wheelchair being transported by Nurse Aide 1 from the 400 hall to the 300 hall. This catheter collection bag did not have a cover and urine was visible. Interview with Nurse Aide 1 on March 31, 2025, at 11:30 a.m. confirmed that there was not a privacy bag on the urine collection bag, and she had been looking for one since this morning.
Interviews with the Director of Nursing on April 1, 2025, at 2:28 p.m. confirmed that Resident 54's catheter tubing should not have been in contact with the fall mat.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of 34 resi...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of 34 residents reviewed (Resident 23).
Findings include:
The facility's policy regarding medication storage, dated January 22, 2025, indicated that medications for internal use were stored in medication carts or other designated areas.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated March 20, 2025, indicated that the resident was cognitively intact, usually understood and could usually understand, required assistance from staff for daily care needs, and was receiving antipsychotic medication.
Physician's orders for Resident 23, dated January 13, 2025, included an order for the resident to receive 25 milligrams (mg) of Seroquel (antipsychotic medication) daily for psychosis.
Interview and observations of Resident 23 on March 31, 2025, at 10:55 a.m. revealed that she was in her room and she stated that her only concern was a pink pill on the floor by her toilet. There was a round pink/orange pill on the floor in her bathroom.
Interview with Licensed Practical Nurse 2 on March 31, 2025, at 11:17 a.m. confirmed that the medication was identified as 25 mg of Seroquel and Resident 23 was scheduled to receive the medication in the evening. Licensed Practical Nurse 2 further explained that Resident 23 was the only resident in that room that used the toilet, and her morning medication were crushed and served with pudding or applesauce.
Interview with the Director of Nursing on April 1, 2025, at 2:28 p.m. confirmed that medication should not be on the floor.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumoco...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal vaccine (prevents bacterial pneumonia) for one of 34 residents reviewed (Resident 5), and failed to ensure that each resident was offered and/or received the influenza vaccine for two of 34 residents reviewed (Residents 11, 14).
Findings include:
The facility's policy regarding vaccines, dated January 22, 2025, revealed that the resident or the resident's representative have the opportunity to accept or refuse immunization.
A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2025, indicated that the resident was cognitively intact and that the resident's pneumococcal was not up to date.
A pneumococcal vaccine authorization form signed by Resident 5, dated November 19, 2024, revealed that she wanted to have the pneumococcal vaccine.
An interview with the Registered Nurse Assessment Coordinator on April 3, 2025, at 11:34 a.m. confirmed that Resident 5 did not receive a pneumococcal vaccine and that she should have.
A quarterly MDS assessment for Resident 11, dated February 20, 2025, revealed that the resident was cognitively intact and that her flu vaccine was not up to date.
A flu vaccine consent form for Resident 11, dated October 2, 2024, revealed that the resident consented to receive the flu vaccine; however, a review of Resident 11's clinical record revealed that she did not receive the flu vaccine.
An interview with the Director of Nursing on April 3, 2025, at 11:28 a.m. confirmed that Resident 11 did not receive the flu vaccine and should have.
A quarterly MDS assessment for Resident 14, dated February 19, 2025, revealed that the resident was understood, could understand, was cognitively intact, and was dependent on staff for her daily care tasks. Section O0250 A of the MDS (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in this facility for this year's influenza vaccination season due to being offered but declining the vaccine.
Review of Resident 14's clinical record revealed that there was no documented evidence that the resident was offered the influenza vaccine for the 2024-2025 flu season.
Interview with the Director of Nursing on April 3 at 12:29 p.m. confirmed that there was no documented evidence that Resident 14 was offered the seasonal influenza vaccine for 2024-2025 flu season.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for f...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to store frozen foods appropriately, failing to keep kitchen equipment clean and sanitary, and failing to have staff wear appropriate hair restraints during food preparation and tray line service.
Findings include:
The facility's policy regarding food labeling and dating, dated January 22, 2024, revealed staff were to properly seal the container of bulk freezer items like frozen vegetables to maintain their integrity.
Observations in the kitchen's walk in freezer on March 31, 2025, at 9:20 a.m. revealed that there was an opened box of frozen fish fillets that was exposed to the air. Interview with the Dietary Director at the time of the observation confirmed that the box of frozen fish should have been sealed and removed the box to have staff cover the fish filets.
The facility's policy regarding sanitizing equipment, dated January 22, 2024, revealed that equipment used in meal preparation was thoroughly cleaned and sanitized preventing injury and food-borne illness.
Observations in the facility's kitchen on March 31, 2025, at 9:33 a.m. revealed that the deep fryer in the meal preparation area had a large amount of floating fried debris on the oil and the surrounding area. The deep fryer was not used for the morning meal and was turned on and heating up for use during the lunch and dinner meals. Interview with the Dietary Director at the time of the observation confirmed that the deep fryer should have been cleaned after use.
The facility's policy regarding dress code guidelines, dated January 22, 2024, revealed that men with beards or full mustaches are not permitted in food production and a beard net must be worn.
Observations of the work/prep space in the kitchen during tray line on April 3, 2024, at 11:15 a.m. revealed that two staff were prepping drinks and trays for trays for residents that ate in their rooms. Dietary Staff 3 had a full beard and mustache and was not wearing a beard restraint. Interview with the Dietary Director on March 3, 2025, at 11:24 p.m. revealed that the dietary staff were to have facial hair restraints while in the kitchen.
28 Pa. Code 211.6(f) Dietary Services.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately document...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of four residents reviewed (Resident 1).
Findings include:
The facility's policy for abuse, dated Janaury 8, 2025, indicated that the incident report process requires a note in the clinical record and subsequent documentation of all assessments and interventions.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 6, 2024, revealed that the resident was cognitively impaired, could usually understand, was understood, was independent with daily care, and had diagnoses of stroke.
A nursing note for Resident 1, dated January 18, 2025, at 10:08 a.m., revealed that the resident was found on the floor, had no complaints of pain, no injury was voiced or noted, and neurological checks (a series of tests that assess the function of the nervous system) were ordered.
A review of the facility's investigation report, dated January 19, 2025, indicated that the resident was found on the floor on January 18, 2025, at 10:08 a.m. and neurological checks were initiated. At 12:30 p.m. the resident had complaints of a dry mouth and was provided a drink without issue. A breathing treatment was given at that time due to the resident's current diagnosis of pneumonia with a cough. At 2:30 p.m. the resident had issues with answering questions. The Physician's Assistant was notified and arrived at the facility to assess the resident and ordered another breathing treatment. At 4:15 p.m. the family returned the call to the facility and was made aware of the incident and the resident's current status. At 6:44 p.m. the resident was no longer able to raise her arm, and new orders were received to send to the resident to the emergency department for evaluation.
There was no documented evidence in Resident 1's clinical record to indicate that registered nurse assessments were conducted on January 18, 2025, at 12:30 p.m. when the resident complained of a dry mouth, at 2:30 p.m. when the resident had issues with answering questions, or at 6:44 p.m. when the resident could no longer raise her arm.
Interview with the Director of Nursing on January 29, 2025, at 10:48 a.m. confirmed that the registered nurse assessments of Resident 1 were completed on January 18, 2025; however, they were not documented in the clinical record and should have been.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(5) Nursing Services.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific an...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address a resident's frequent urinary tract infections and medication use for one of three residents reviewed (Resident 1).
Findings include:
The facility's policy regarding care planning, dated March 26, 2024, revealed that the comprehensive care plan was to have input from interdisciplinary team members, and to the extent practicable, the participation of the resident and/or the resident's representative(s). The care plan was to contain interdisciplinary approaches, be oriented toward involving the resident, and address additional areas that are relevant to meeting the resident's needs in the long-term care setting.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 7, 2024, indicated that the resident was understood and could usually understand, required assistance from staff for care needs, and was frequently incontinent of urine and occasionally incontinent of bowel.
Physician's orders for Resident 1, dated July 4, 2024, included an order for the resident to be administered one gram D-mannose (Cranberry supplement) daily for urinary tract infection (UTI) prophylaxis (prevention). Physician's orders, dated July 8, 2024, included an order for the resident to be seen by urology related to frequent UTI and burning and painful urination. Physician's orders, dated July 28, 2024, included an order for the resident to be administered 0.01 percent Estradiol (vaginal cream) daily for urinary tract infection prevention. Physician's orders, dated August 3, 2024, included an order for the resident to be administered 100 milligrams (mg) of Macrobid (antibiotic) twice a day for five days.
There was no documented evidence that a care plan was created for Resident 1's frequent UTI's and antibiotic use.
Interview with the Director of Nursing on August 7, 2024, at 4:29 p.m. confirmed there was no care plan created for the care and treatment of frequent UTI's, antibiotic medication, and preventative medication.
28 Pa. Code 201.24(e)(4) admission Policy.
May 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medica...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 31 residents reviewed (Resident 48).
Findings include:
The facility policy regarding privacy of health information, dated March 26, 2024, indicated that the facility was to protect the confidentiality of a resident's health information.
Observations during medication administration on May 14, 2024, at 8:21 a.m. revealed that Licensed Practical Nurse 3 walked away from her medication cart to take the blood pressure of Resident 48 without securing her computer screen. Resident 48's personal health information was visible on the computer screen, which was facing the hallway. Upon return to the cart after obtaining the blood pressure, Licensed Practical Nurse 3 retrieved medication to administer to Resident 48 and again left the computer screen unsecured with Resident 48's personal health information visible and facing the hallway.
Interview with Licensed Practical Nurse 3 on May 14, 2024, at 8:27 a.m. confirmed that she should have covered Resident 48's personal information on the computer screen when leaving the medication cart.
Interview with the Director of Nursing on May 16, 2024, at 8:41 a.m. confirmed that the computer screen with residents' personal health information should have been covered when the nurse was not attending the medication cart.
28 Pa. Code 211.5(b) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standar...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to further assess an elevated blood pressure for one of 31 residents reviewed (Resident 29).
Findings include
The facility's policy regarding vital signs, dated March 26, 2024, revealed that vital signs are a measure of a resident's condition that assist in providing necessary services. The American Medical Association, Best Practice guidelines for blood pressure, dated December 2018, revealed that providers need to be aware of blood pressures that are out of range so they can act rapidly to intervene as appropriate.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 26, 2024, revealed that the resident was moderately cognitively impaired, usually understood and understands, and had diagnoses that include chronic kidney disease and primary hypertension (high blood pressure). Physician orders for Resident 29, dated April 10, 2024, included an order for the resident to receive 20 milligrams (mg) of Lisinopril (used to treat high blood pressure) twice a day and 6.25 mg of Carvedilol (used to treat high blood pressure) twice a day for hypertension.
A physician's assistant note for Resident 29, dated April 22, 2024, indicated that the resident was currently being followed for both orthostatic hypotension (low blood pressure when standing quickly) and essential hypertension (abnormally high blood pressure), in addition to syncopal (fainting) episodes and related falls.
Review of Resident 29's clinical record for May 12, 2024, indicated that at 8:40 p.m. her blood pressure was 139/94 millimeters of mercury (mm/Hg) and at 8:51 a.m. her blood pressure was recorded as 197/86 mm/Hg.
The American College of Cardiology and the American Heart Association determined that a normal blood pressure is 120/80 mm/Hg.
There was no documented evidence in Resident 29's clinical record for May 13, 2024, that the elevated blood pressure of 197/86 mm/Hg was reassessed.
Interview with Registered Nurse 1 on May 16, 2024, at 10:20 a.m. confirmed that Resident 29 has variable blood pressures; however, an elevated pressure of 197/86 mm/Hg would warrant a recheck and evaluation of the resident. Further assessment would include, rechecking the blood pressure with a different type of cuff, administering blood pressure meds as ordered and then rechecking the blood pressure with in an hour, alerting the MD as needed, and documentation in the residents progress notes.
Interview with Licensed Practical Nurse 2 on May 16, 2024, at 12:01 p.m. confirmed that she works with Resident 29 and if she obtained a blood pressure reading of 197/86 mm/Hg she would immediately retake the pressure with a different type of cuff or an automatic style cuff and if it was still elevated, she would alert the registered nurse to call the doctor and document any findings in the resident's progress notes.
Interview with the Director of Nursing on May 16, 2024, at 3:30 p.m. confirmed that Resident 29 had an elevated blood pressure that warranted further assessment, which was not done, and should have been.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possi...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 31 residents reviewed (Resident 47).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 47, dated March 29, 2024, revealed that the resident was cognitively impaired, required moderate assistance for all of her care, and used a wheelchair.
Observations on May 13, 2024, at 11:44 a.m. revealed that Registered Nurse 4 pushed Resident 47 in a wheelchair without any leg/foot rests from her room through the hallway and into the dining room while the resident elevated her feet. The leg/foot rests were not on the resident's wheelchair.
An interview with Registered Nurse 4 on May 13, 2024, at 11:47 a.m. revealed that she was aware that leg rests were to be used when transporting Resident 47 in her wheelchair.
An interview with the Director of Nursing on May 13, 2024, at 2:34 p.m. confirmed that staff, agency staff, and hospice staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on facility policy, federal regulations, and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary ...
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Based on facility policy, federal regulations, and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 31 residents reviewed (Resident 14).
Findings include:
The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that comments and recommendations concerning medication therapy would be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.
Federal Regulations require that as-needed orders for psychotropic drugs be limited to 14 days. Except when the attending physician or prescribing practitioner believes that it is appropriate for the as-needed order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the as-needed order.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 6, 2023, revealed that the resident was severely cognitively impaired, required assistance with daily care needs, and had diagnoses that included depression and dementia.
Physician's orders for Resident 14, dated December 14, 2023, included an order for the resident receive a 5 milligram (mg) injection of Zyprexa (an antipsychotic) daily as needed for combativeness. There was no documented evidence that the order was discontinued after 14 days.
A January 2024 medication administration record for Resident 14 revealed that the resident was administered a
5 mg injection of Zyprexa on January 1 and 24, 2024.
A review of clinical records, including physician progress notes and consultant pharmacist recommendations to the physician for December 2023 and January 2024, for Resident 14 revealed no documented rationale for the long-term use of Zyprexa as needed, as required by federal regulations.
An interview with the Director of Nursing on May 16, 2024, at 3:30 p.m. confirmed that there was no documented rationale for the long-term use of as-needed Zyprexa by the attending physician or by a psychiatric consultant.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to ensure that controlled medications were stored in a separately locked, permanently-affixed compartment in one of two medication refrigerators reviewed (Main), failed to label medications with the date they were opened in one of two medication rooms reviewed (Main Medication Room) and in one of two medication carts reviewed (200 hall).
Findings include:
The facility's policy regarding the security of the medication cart, dated March 26, 2024, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry, and the medication cart was to be securely locked at all times when out of the nurse's view.
Observations on May 14, 2024, at 8:21 a.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 3 when she went into Resident 47's room to take his blood pressure and again at 8:25 a.m. when she took medications to the resident.
Interview with Licensed Practical Nurse 3 on May 14, 2024, at 8:27 a.m. confirmed that her medication cart should have been locked when unattended.
Interview with the Director of Nursing on May 16, 2023, at 8:01 a.m. confirmed that the medication cart should have been locked when unattended by Licensed Practical Nurse 3.
The facility's policy regarding medication storage, dated March 26, 2024, indicated that medications and biologicals are to be stored safely, securely and properly.
Observations of the Main medication room refrigerator on May 15, 2024, at 3:49 p.m. revealed that there was a narcotic storage box containing five (2mg/ml) bottles of Ativan (a controlled medication used to treat anxiety) that was not permanently affixed inside the refrigerator.
An interview with Registered Nurse 5 on May 15, 2024, at 4:00 p.m. confirmed that the narcotic storage box was not permanently affixed inside the refrigerator.
An interview with the Assistant Director of Nusing on May 15, 2024, at 4:51 p.m. confirmed that the narcotic storage box was not permanently affixed inside the refrigerator, and it should have been.
The facility's policy regarding medication administration, dated March 26, 2024, revealed that once opened, a multi-dose vial was to have the date it was opened recorded on the container.
An undated package insert for Tubersol (used to test for tuberculosis - a bacterial infection) revealed that once entered/opened, the vial was to be discarded after 30 days.
Observations in the Main medication room refrigerator on May 15, 2024, at 3:52 p.m. revealed that an opened vial of Tubersol was not properly labeled with the date it was opened.
An interview with Registered Nurse 5 on May 15, 2024, at 4:00 p.m. confirmed that the opened vial of Tubersol was not properly labeled with the date it was opened.
An interview with the Assistant Director of Nursing on May 15, 2024, at 4:51 p.m. confirmed that an opened vial of Tubersol was not properly labeled with the date it was opened, and it should have been.
An undated package insert for Insulin Lispro (a medication used to treat diabetes) revealed that once opened, the pen was to be discarded after 28 days.
Observations in the Medication Cart for 200 Hall on May 14, 2024, at 11:19 a.m. revealed that an opened Insulin Lispro pen for Resident 65 was not properly labeled with the date it was opened.
An interview with Licensed Practical Nurse 2 on May 15, 2024, at 11:25 a.m. confirmed that the opened Insulin Lispro pen for Resident 65 was not properly labeled with the date when it was opened, and it should have been.
An interview with the Assistant Director of Nursing on May 16, 2024, at 8:01 a.m. confirmed that an opened Insulin Lispro pen should have been dated when opened and discarded after 28 days.
28 Pa. Code 211.9(a)(1)(k) Pharmacy Services.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents revi...
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Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents reviewed (Residents 3, 14).
Findings include:
The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.
Review of the clinical records for Resident 3 and Resident 14 revealed no documented evidence that the monthly review of medications by the pharmacist were addressed by the physician or designee in December 2023 and January 2024.
Interview with the Director of Nursing on May 16, 2024, at 2:57 p.m. confirmed that there was no documented evidence that the December 2023 and January 2024 monthly medication reviews for Residents 3 and 14 were addressed by the medical provider.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(3) Nursing Services.
Jul 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification upon hire for one of three nurse...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification upon hire for one of three nurse aides reviewed (Nurse Aide 1).
Findings include:
The facility's policy regarding abuse and screening potential employees, dated June 15, 2023, revealed that the purpose of the policy was to ensure that applicants for positions requiring state nurse aide registry and/or certified applicants with records of abuse, neglect mistreatment of residents, or misappropriation of their property were not hired. The records shall be obtained and documented prior to extending an offer of employment.
The personnel file for Nurse Aide 1 revealed that she was hired on March 14, 2023. As of July 6, 2023, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to hire.
Interview with the Nursing Home Administrator on July 6, 2023, at 1:16 p.m. confirmed that there was no documented evidence of a nurse aide registry check being completed as required upon hire for Nurse Aide 1.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that recommended contracture management services were provided as care planned for one of 23 residents reviewed (Resident 28).
Findings include:
The facility's policy regarding splints, braces, prosthetics, and immobilization devices, dated June 15, 2023, indicated that devices were to be applied according to manufacturer's instructions or therapy directives and any device use was to be part of the resident's individualized plan of care.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated June 8, 2023, indicated that the resident had severe cognitive impairment, was rarely or never understood, required extensive assistance of two staff for daily care tasks, and had current diagnoses of Alzheimer's disease and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). A care plan for the resident, dated January 30, 2023, revealed that the resident had impaired Activities of Daily Living (ADL- essential and routine tasks that most young, healthy individuals can perform without assistance), functional status, and rehabilitation deficit. Staff were to apply [NAME] hand/palm splints (inflatable splints that help with range of motion and contractures) on both hands to be worn at all times except during hygeine.
An occupational therapy note for Resident 28, dated January 31, 2023, indicated that the resident was lying in bed without the [NAME] splints in place. The splints were put on the resident and nursing staff was educated on the use of the splints. The splints were in place to increase range of motion and decrease the risk for contractures.
Observations of Resident 28 on July 6, 2023, 2:40 p.m. revealed that the resident was in her broda chair with one splint on the left hand and no splint on the right hand. Observations of Resident 28 on July 7, 2023, at 1:17 p.m. revealed that the resident was in her broda chair with with one splint on the left hand and no splint on the right hand. Interview with Nurse Aide 2 on July 7, 2023, at 1:27 p.m. confirmed that the resident only had one splint in use, was unsure where the other splint was, and must have forgotten to place the small stuffed animal in the other hand as per family preference.
Interview with the Director of Therapy on July 7, 2023, at 1:05 p.m. revealed that the splints were therapeutic for contracture management and prevention. However, the family will routinely remove the splints and replace them with small stuffed animals, items that the family used prior to Resident 28's admission.
Interview with the Director of Nursing on July 7, 2023, at 2:25 p.m. confirmed that Resident 28 was to have two hand splints in place as care planned and that the other splint was found in the closet.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's weight as recommended by the dietician for one of 23 r...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's weight as recommended by the dietician for one of 23 residents reviewed (Resident 4).
Findings include:
The facility's policy regarding weight loss, dated June 15, 2023, revealed that residents would be reweighed if necessary to obtain an accurate weight.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 9, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care needs.
A dietician note for Resident 4, dated January 9, 2023, revealed that the resident had a weight loss of 7.2 pounds in one week and that there were weight fluctuations noted. She ordered daily weights for seven days from January 9-15, 2023, to determine if the resident was having weight loss. However, the resident's weight was not obtained on January 13, 14, or 15. When the resident's weight was obtained on January 16, 2023, she had an 8-pound weight loss. She was weighed on January 23, 2023, and had a 10-pound weight gain.
There was no documented evidence that daily weights were obtained as recommended for January 13, 14 or 15, 2023, and that the resident had both a weight gain of 8-pounds and a loss of 10-pounds that were not addressed by the dietician until January 27, 2023.
An interview with the Director of Nursing on July 7, 2023, at 2:27 p.m. confirmed that Resident 4 was not weighed according to the dietician's recommendations and that she should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on a review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually, based on dates ...
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Based on a review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually, based on dates of hire, for one of three nurse aides reviewed (Nurse Aide 4).
Findings include:
A review of the personnel file for Nurse Aide 4 revealed that she was hired on September 4, 2021.
There was no documented evidence that an annual performance evaluation, based on the date of hire, was completed as required for 2022.
Interview with the Director of Nursing on July 7, 2022, at 4:04 p.m. confirmed that Nurse Aide 4's annual performance evaluation was not completed and should have been.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 201.20(a)(c) Staff development.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were follow...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 23 residents reviewed (Resident 25).
Findings include:
The facility's medication administration policy, dated June 15, 2023, indicated that staff was to pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves.
Observations during medication administration on July 6, 2023, at 7:48 a.m. revealed that while preparing medications for Resident 25, Licensed Practical Nurse 5 went to remove the medications from a sealed plastic package to place the medications into a medication souffle cup; however, she missed the medication souffle cup and one of the medications landed on top of the medication cart. With her bare fingers Licensed Practical Nurse 5 picked the medication up and placed it into the medication souffle cup. She continued to prepare Resident 25's medications. Upon completion of preparing Resident 25's medications she then administered the medications to the resident at 7:50 a.m.
Interview with Licensed Practical Nurse 5 on July 6, 2023, at 7:56 a.m. confirmed that she should not have not have touched Resident 25's medications with her bare fingers.
Interview with the Director of Nursing on July 7, 2023, at 9:45 a.m. confirmed that Licensed Practical Nurse 5 should not have touched Resident 25's medications with her bare fingers.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, observations,and staff interviews, it was determined that the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, observations,and staff interviews, it was determined that the facility failed to review and revise care plans for five of 23 residents reviewed (Residents 4, 13, 28, 35, 45).
Findings include:
The facility's policy regarding care plans, dated June 15, 2023, indicated that the care plan would contain realistic, measurable goals for each problem and interdisciplinary approaches, and would be updated electronically as needed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 9, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care needs. A care plan for Resident 4, revised June 9, 2023, revealed that the resident was a fall risk.
A facility investigation report for Resident 4, dated March 2, 2023 revealed that the resident was found on the floor and that she fell out of bed. A new intervention related to the fall was to give the resident a lipped mattress (a mattress with slightly raised edges to help with prevent falls).
As of July 7, 2023, there was no documented evidence that a care plan was revised to reflect that Resident 4 had a lipped mattress.
Interview with the Director of Nursing on July 7, 2023, at 3:41 p.m. confirmed that the care plan was not updated to indicate that Resident 4 had a lipped mattress.
A quarterly MDS assessment for Resident 13, dated May 31, 2023, revealed that the resident was cognitively intact and required minimal assistance from staff for her daily care needs. The resident's care plan, revised May 31, 2023, revealed that she had asthma (a breathing disorder).
Physician's orders for Resident 13, dated December 29, 2022, indicated that the resident required oxygen to be delivered at 2 liters per minute via nasal cannula at night for asthma.
As of July 7, 2023, there was no documented evidence that a care plan was revised to reflect that Resident 13 received oxygen at night.
Interview with the Director of Nursing on July 7, 2023, at 4:04 p.m. revealed that Resident 13's care plan was not updated to indicate that she received oxygen at night.
A quarterly MDS assessment for Resident 28, dated June 8, 2023, indicated that the resident had severe cognitive impairment, was rarely or never understood, required extensive assistance of two staff for daily care tasks, had current diagnoses of Alzheimer's disease and Parkinson's disease (an impaired nervous system causing tremor, muscular rigidity, and slow movement). The resident's care plan, dated January 30, 2023, revealed that the resident had impaired Activities of Daily Living (ADL- essential and routine tasks that most young, healthy individuals can perform without assistance), functional status, and rehabilitation deficit. Staff were to apply [NAME] hand/palm splints (inflatable splint used to increase range of motion and prevent contracture) in both hands to be in place at all times except during hygeine.
An occupational therapy note for Resident 28, dated January 31, 2023, indicated that the resident was lying in bed without the [NAME] splints in place. The splints were put on her and the nursing staff was educated on the use of the splints. The splints were in place to increase range of motion and decrease the risk for contractures.
Observations of Resident 28 on July 6, 2023, 2:40 p.m. revealed that the resident was in her broda chair with one splint on the left hand and no splint on the right hand. Observations of Resident 28 on July 7, 2023, at 1:17 p.m. revealed that the resident was in her broda chair with with one splint on the left hand and no splint on the right hand. Interview with Nurse Aide 2, on July 7, 2023, at 1:27 p.m. confirmed that the resident only had one splint on and was unsure where the other splint was. Nurse Aide 2 also stated that she forgot to place a small stuffed animal in the resident's hand per the family's preference.
Interview with the Director of Therapy on July 7, 2023, at 1:05 p.m. revealed that Resident 28 was to have splints on both of her hands for contracture management at all times; however, family members would routinely replace the splints with small stuffed animals.
Interview with the Director of Nursing on July 7, 2023, at 3:42 p.m. confirmed that Resident 28's care plan was not updated to reflect that the resident's family preferred to use small stuffed animals for contracture management, and that it should have been.
An admission MDS assessment for Resident 35, dated June 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance of two staff for daily care tasks, and had a urinary catheter with diagnoses that included obstructive uropathy (urine can not drain due to blockage).
Physician's orders for Resident 35, dated June 6, 2023, included an order for the resident to receive bilateral nephrostomy tube (tubes inserted to drain urine from the kidneys) dressing changes and for the areas to be cleansed with normal saline with the application of a 4-inch by 4-inch covrsite (wound dressing) daily. Physician's orders for Resident 35, dated June 8, 2023, included orders to empty the left and right nephrostomy tubes daily and record the amount of milliters (ml) and to have the bilateral nephrostomy tubes flushed daily with 10 ml of normal saline.
Resident 35's bowel and bladder care plan, dated June 6, 2023, revealed no documented evidence that the care and treatment for nephrostomy tubes was included.
Interview with the Director of Nursing on July 7, 2023, at 1:45 p.m. confirmed that Resident 35's care plan was not updated to reflect that the resident was receiving daily care and treatment to the nephrostomy tubes.
A quarterly MDS assessment for Resident 45, dated June 25, 2023, revealed that the resident was cognitively intact and required assistance from staff for his daily care needs. The resident's care plan, revised June 25, 2023, revealed that the resident was at risk of developing a blood clot.
Physician's orders for Resident 45, dated February 17, 2023, revealed that the resident was to receive 5,000 unit/milliliter of heparin sodium (a blood thinner) subcutaneously (fatty tissue under the layers of skin) twice a day for 10 days to be complete on February 26, 2023. The resident's care plan as of July 7, 2023, indicated that the resident was still receiving the heparin. Physician's orders for Resident 45, dated June 17, 2023, included orders for the resident to have a 16 French 15 cubic centimeters (cc) balloon (specific size) urinary catheter. Resident 45's care plan, dated March 12, 2023, indicated that the resident had a 16 French 10 cc balloon urinary catheter.
Observations of Resident 45 on July 7, 2023, at 11:14 a.m. revealed that he had a 14 French 10 cc balloon urinary catheter.
Interview with Licensed Practical Nurse 3 on July 7, 2023, at 11:14 a.m. revealed that Resident 45's urinary catheter should be a 14 French 10 cc balloon and that the physician's order and care plan did not match what the resident had because of the back order of supplies.
An interview with the Director of Nursing on July 7, 2023, at 11:25 a.m. confirmed that Resident 45 was no longer receiving heparin and that his care plan should have been revised. She also confirmed that the resident's urinary catheter size should match the physician's order and the care plan. She revealed that the urologist specifically wanted a 14 French 10 cc balloon urinary catheter and that the care plan should have matched.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate discharge Minimum...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate discharge Minimum Data Set assessments for one of 23 residents reviewed (Resident 54).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section A2100 (Discharge Status) was to be coded one (1) through eight (8) depending on the location of the resident's discharge. If the resident was discharged to the community (including a boarding home or assisted living facility) or home, then Section A2100 was to be coded one (1), and if the resident was discharged to an acute care hospital, then Section A2100 was to be coded three (3).
A nursing progress note for Resident 54, dated April 21, 2023, revealed that the resident was discharged home with his wife and all personal belongings that day at 1:30 p.m. The resident's medications were counted and sent home with the resident. The resident was stable at discharge.
A social services progress note for Resident 54, dated April 20, 2023, revealed that a discharge MDS assessment was completed with an Assessment Reference Date (ARD) of April 20, 2023, and that the resident will be going home with Home Health physical therapy, occupational therapy, and a registered nurse.
A discharge MDS assessment for Resident 54, dated April 21, 2023, revealed that Section A2100 was coded three (3), indicating that the resident was discharged to an acute care hospital.
Interview with Registered Nurse/Infection Preventionist/Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on July 7, 2023, at 3:45 p.m. confirmed that Section A2100 of Resident 54's discharge MDS assessment of April 21, 2023, was not accurate and should have been coded to indicate that the resident was discharged to the community.
28 Pa. Code 211.5(f) Clinical records.
May 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored and treated for one of five residents reviewe...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored and treated for one of five residents reviewed (Resident 2).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2023, revealed that the resident was usually understood and was usually able to understand others, required extensive assistance with daily care needs, did not have any pressure ulcers, had a skin tear, and had diagnoses that included dementia.
An admission skin evaluation for Resident 2, dated May 2, 2023, revealed that the resident had a skin tear to his right shin, measuring 6.0 centimeters (cm) by 1.5 cm with surrounding bruising measuring 6.0 cm by 3.0 cm, and had a red blanchable (normal white color appears when skin is pressed) area to his right heel.
Physician's orders for Resident 2, dated May 2, 2023, included an order for the resident to have the partial skin tear on his right shin cleansed with normal saline, pat dry, and apply a silicone foam adhesive dressing with border, to be changed as needed. The order was discontinued on May 3, 2023.
Physician's orders for Resident 2, dated May 2, 2023, included an order to apply no sting barrier wipe to bilateral heels every shift. The order was discontinued on May 12, 2023.
Physician's orders for Resident 2, dated May 12, 2023, included an order to cleanse the right heel with normal saline, pat dry, apply hydrogel (used to promote wound healing by providing a moist environment) and cover with secondary dressing, change every three days. The order was discontinued on May 15, 2023.
Physician's order for Resident 2, dated May 12, 2023, included an order to cleanse the right heel and left heel with normal saline, pat dry, apply hydrogel and cover with secondary dressing, change every three days. The order was discontinued on May 18, 2023.
A review of Resident 2's Treatment Administration Record (TAR) for May 2023 revealed no documented evidence that any treatment was completed on the resident's left heel between May 12, 2023, and May 18, 2023.
A nurse's note for Resident 2, dated May 14, 2023, revealed that a new wound was noted on the resident's right shin. Physician's orders, dated May 14, 2023, included an order for the resident to have his right shin cleansed with normal saline, pat dry and apply telfa (non-stick absorbent cotton gauze) and adaptic (non-stick dressing that contains oil), change daily until seen by wound consultant.
A review of Resident 2's wound consultations for May 2, May 9, and May 16, 2023, revealed that the resident's bilateral heels and skin tear to the right shin were not assessed by the wound care consultant until May 16, 2023.
An interview with the Director of Nursing on May 30, 2023, at 4:03 p.m. confirmed there was documentation of Resident 2 having a skin tear on his left shin on admission; however, there was no documentation that the skin tear was monitored or treated until May 14, 2023, when it was documented as a new skin tear. Further interview with the Director of Nursing on May 30, 2023, at 4:27 p.m. confirmed that there was no documentation that treatments were being completed to the pressure ulcer on the resident's left heel between May 12, 2023, and May 18, 2023.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident had effective interventions in place for fall prevention for ...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident had effective interventions in place for fall prevention for one of five residents reviewed (Resident 5).
Findings include:
The facility's policy regarding falls management, dated February 21, 2023, indicated that the facility will provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 17, 2023, revealed that the resident understood and could usually understand, was cognitively impaired, required extensive assistance from staff for daily care needs, and had medical diagnoses that included high blood pressure, adjustment disorder, and history of falls.
A nursing note for Resident 5, dated May 23, 2023, at 10:59 a.m. revealed that the resident had an unwitnessed fall while transferring himself to his wheelchair.
Fall investigation documents for Resident 5, dated May 23, 2023, revealed that the interdisciplinary team's intervention for the fall included anti-tippers and anti-roll backs on his wheelchair.
A nursing note for Resident 5, dated May 29, 2023, at 7:45 p.m., revealed that the resident had an unwitnessed fall. The facility's investigation was unable to determine if the resident's fall was from the wheelchair or recliner.
Observations on May 30, 2023, at 2:33 p.m. revealed that Resident 5's wheelchair did not have anti-tippers or anti-rollbacks on it.
Interview with Physical Therapist 1 on May 30, 2023, at 2:37 p.m. confirmed that Resident 5 did not have anti-tippers or anti-roll backs on his wheelchair.
Interview with the Director of Nursing on May 30, 2023, at 3:34 p.m. confirmed that Resident 5 did not have the anti-tippers and anti-rollbacks on his wheelchair and that they should have been in place to prevent reoccurring falls.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of five res...
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Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of five residents reviewed (Resident 2).
Findings include:
A facility policy for Medication Administration, dated February 21, 2023, indicated that all residents shall receive all medications per the orders of the physician, including the correct dosage, time, route, and frequency.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2023, revealed that the resident was usually understood and was usually able to understand others, required extensive assistance with daily care needs, and had diagnoses that included dementia.
Physician's orders for Resident 2, dated May 1, 2023, included an order for the resident to receive 14 units of Insulin lispro (used to lower blood sugar levels) after dinner, to be given only if the resident consumed fifty percent or more of his meal.
A review of the Medication Administration Records (MAR's) for Resident 2 for May 24, 2023, revealed that 14 units of insulin were administered into the resident's right abdomen at the 5:00 p.m. dinner meal; however, the resident's meal intake was documented as zero.
A nurse's note for Resident 2, dated May 24, 2023, at 11:19 p.m. revealed that the resident was lethargic (abnormally drowsy) and had a blood glucose level of 37 milligrams per deciliter (mg/dL) requiring an intramuscular injection of Glucagon (a natural substance that raises blood sugar by causing the body to release sugar stored in the liver).
Interview with the Director of Nursing on May 30, 2023, at 4:03 p.m. confirmed the documentation revealed that Resident 2 consumed zero percent of his dinner on May 24, 2023, and should not have received the 14 units of insulin lispro.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- • 44% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Westminster Woods At Huntingdo's CMS Rating?
CMS assigns WESTMINSTER WOODS AT HUNTINGDO an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Westminster Woods At Huntingdo Staffed?
CMS rates WESTMINSTER WOODS AT HUNTINGDO's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 44%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Westminster Woods At Huntingdo?
State health inspectors documented 25 deficiencies at WESTMINSTER WOODS AT HUNTINGDO during 2023 to 2025. These included: 24 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Westminster Woods At Huntingdo?
WESTMINSTER WOODS AT HUNTINGDO is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by PRESBYTERIAN SENIOR LIVING, a chain that manages multiple nursing homes. With 64 certified beds and approximately 59 residents (about 92% occupancy), it is a smaller facility located in HUNTINGDON, Pennsylvania.
How Does Westminster Woods At Huntingdo Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, WESTMINSTER WOODS AT HUNTINGDO's overall rating (2 stars) is below the state average of 3.0, staff turnover (44%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Westminster Woods At Huntingdo?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Westminster Woods At Huntingdo Safe?
Based on CMS inspection data, WESTMINSTER WOODS AT HUNTINGDO has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Westminster Woods At Huntingdo Stick Around?
WESTMINSTER WOODS AT HUNTINGDO has a staff turnover rate of 44%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Westminster Woods At Huntingdo Ever Fined?
WESTMINSTER WOODS AT HUNTINGDO has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Westminster Woods At Huntingdo on Any Federal Watch List?
WESTMINSTER WOODS AT HUNTINGDO is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.