Skip to main content
ReadyRule homepageReadyRule

Inspection visit

Incident investigation

PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENSLicense 1572092972 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPA)'s Daiquiri Boyd and Shawna Doucette arrived at the facility unannounced to conduct a case management for an incident that occurred on 5/5/25. LPA's met with Administrator Nicole Morehead. LPA's interviewed the Administrator. R1 had a prescription for .25 ml of morphine. and facility received 1 ml. of morphine. Facility logged into the centrally stored log they received .25 ml. Facility administered the 1 ml for 4 days totalling 6 doses. The dates administered 5/2/25 at 8 PM to 5/5/25 8 AM. Facility did not have an order to administer 1 ml every 12 hours to R1. Facility did not have R1's PRN logged as received for 1 ML of morphine on the centrally stored log. Facility centrally stored log showed .25 ML Facility noted on MARS log they administered .25 ml when they actually administered 1 ml. An exit interview was conducted with the Administrator and a copy of this report was provided with appeal rights and plan of correction.

Citations

9 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.625(b)(2)Type B

    Based on record review, the licensee did not comply with the section cited above in all staff counts which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87609(b)(4)Type B

    Agree in writing on agency and facility responsibilities

    Based on record review, the licensee did not comply with the section cited above in two out of the seven files which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87633(b)Type B

    Facility must keep complete hospice care plan on file

    Based on record review, the licensee did not comply with the section cited above in 2 out of 2 client files which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87633(b)(6)(B)Type B

    Based on record review, the licensee did not comply with the section cited above in two out of two files which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87303(e)(3)Type A

    Mark taps at high-temperature threshold

    Based on observation, the licensee did not comply with the section cited above in facility which poses an immediate health, safety or personal rights risk to persons in care.

  • 87555(b)(25)Type A

    Separate storage for cleaning chemicals

    Based on observation], the licensee did not comply with the section cited above in the hall closet it was observed food stored with disposed bio-hazard material which poses an immediate health, safety or personal rights risk to persons in care.

  • 87555(b)(26)Type B

    Onsite food stock levels for nonperishables and perishables

    Based on observation, the licensee did not comply with the section cited above in the kitchen, refrigerator, freezer, and food storage, there is not enough food on hand for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(a)(4)Type A

    Assist residents with self-administered medication

    87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Licensee administered 1 ml of morphine instead of the prescribed dose of .25 ml on 5/2/25 8 PM to 5/5/25 8 AM, which poses an immediate health safety and or personal rights risk to residents in care.

  • 87465(h)(6)(C)Type B

    (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirement was not met as evidenced by LIcensee logged in the wrong strength of morphine for R1. Licensee received 1 ML of morphine and logged on the centrally stored log .25 ml was received for R1, which poses a potential health safety and or personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the May 22, 2025 inspection of PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS?

This was an other inspection of PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS on May 22, 2025. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to PATHWAY ASSISTED LIVING/ WESTCHESTER GARDENS on May 22, 2025?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "Based on record review, the licensee did not comply with the section cited above in all staff counts which poses/posed a..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

Share this reportEmail

Next steps

If this is your facility,claim this pageand correct anything the record gets wrong. Free.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.