Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical records, observations, and staff interviews, it was determined that the facility failed to protect the
residents' rights for two of 32 residents reviewed (Resident R31 and R43).
Findings include:
Resident R31 was admitted to the facility on [DATE], with the following diagnosis: hemiplegia and
hemiparesis following cerebral infarction affecting right dominant side (stroke and complete paralysis of
right side), muscle wasting and atrophy, not elsewhere classified, multiple sites, and difficulty in walking, not
elsewhere classified.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident R31, dated December 25, 2025, revealed that the resident required supervision or
touching assistance for upper body dressing and substantial/maximal assistance for lower body dressing.
An interview conducted with Resident R31 on January 11, 2025, at 10:23 a.m. revealed Resident R32 was
waiting on staff assistance to change out of her hospital gown and into clothing the resident had picked out.
Observations conducted of Resident R31 on January 11, 2025, at 12:00 p.m., 1:15 p.m. and 2:02 p.m.
revealed Resident R31 was still in her hospital gown and waiting for staff to assist her in changing.
An interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on
January 14, 2025, at 1:13 p.m. confirmed that nursing staff should have assisted Resident R31 in changing
from her hospital gown into appropriate personal clothing. The failure to provide timely assistance limited
the residents' right to be treated with dignity and respect.
Resident 43 was admitted to the facility on [DATE], with medical diagnoses that include Lack of
Coordination, Abnormalities of Gait and Mobility, (unusual walking patterns and movement disorders that
can affect balance and coordination), Muscle Wasting and Atrophy (loss of muscle mass or strength),
Muscle Weakness and Intervertebral Disc Degeneration Lumbar Region (breakdown of discs that cushion
the vertebrae in the lower back leading to pain and discomfort).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 43, dated December 21, 2025, revealed that the resident required set up or
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
395173
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
clean up assistance with eating.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 43's care plan revealed a focus dated September 18, 2018, noting the resident requires
assistance with his activities of daily living (adls) related to fatigue, impaired balance, and limited mobility.
Interventions included Eating: the resident feeds self independently set up assist as needed, last revised
May 20, 2021.
Residents Affected - Few
Review of Resident 43's Occupational Therapy (OT) Discharge summary dated [DATE], revealed on
December 4, 2025, the resident's eating baseline was partial to moderate assistance to scoop food and
perform hand to mouth during self-feeding.
Further review of Resident 43's OT discharge summary revealed the resident was discharged from therapy
on December 21, 2025, requiring supervision or touch assistance for scooping food and performing hand to
mouth during self-feeding.
Observations made of breakfast service, in the 2nd floor dining room, on January 11, 2025, at 9:35 a.m.,
revealed Nurse Aide Employee E4 standing over Resident 43, feeding him/her breakfast.
Observations made of lunch service, in the 2nd floor dining room, on January 11, 2025, at 1:10 p.m.,
revealed Employee E4 again standing over Resident 43, feeding him/her lunch.
Observations made on January 12, 2025, at 9:09 a.m., revealed Resident 43 attempting to feed him/herself
in bed, oatmeal and coffee were observed on the resident's tray, bed table and hospital gown. The resident
was observed attempting to drink coffee from a cup which still had a lid on it. The coffee was observed
leaking from the cup onto the resident's chest.
Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December
13, 2025, at 1:47 p.m., when the above information was presented, the DON stated the reason Employee
E4 was standing while feeding Resident 43 was because Employee E4 has a medical condition involving
his/her knees which prohibits him/her from sitting for long periods of time.
Employee E4 standing while feeding Resident 43 limited the resident's right to be treated with dignity and
respect.
28 Pa. Code 201.29(j) Resident Rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395173
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on clinical records review and staff interviews, it was determined that the facility failed to follow
physician orders regarding administration of nutrition for one of three residents reviewed (Resident 11).
Findings include: Review of Resident 11's diagnosis list revealed, nutritional deficiency unspecified
(inadequate supply of essential nutrients in the diet which can lead to malnutrition or disease) and
huntington's disease (inherited genetic condition that causes the general breakdown of nerve cells in the
brain). Review of Resident 11's physicians order revealed an order dated October 17, 2025, for Enteral
Feed Order one time a day for Feeding Continuous Tube Feeding: Product: Jevity 1.5 At 65 ML/ Hour via
peg tube. Up at: 1600 Down when total volume of 1300MLs have been infused. Total Calories: 1950 kcal.
Review of Resident 11's medication administration record (MAR) for October and November 2025 revealed
Resident 11 received a total Jevity 1.5 volume on October 1- 1000ml; October 8 no amount recorded;
October- 11, 13, 14 900ml; October 15-820ml; November 18-839ml and November 25-607ml. The facility
failed to ensure Resident 11's physician order regarding continuous tube feeding for the total volume of
1300 ml was followed. Interview with licensed Director of Nursing on January 14,2026 at approximately
12:30pm confirmed that tube feeding order was not being documented correctly. 28 Pa. Code 211.5(f)
Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Event ID:
Facility ID:
395173
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on policy reviews, clinical records review and staff interviews, it was determined that the facility failed
to develop physician orders regarding respiratory care for 1 of eight resident's reviewed (Resident
2).Findings include:Review of Resident 2's face sheet revealed medical diagnoses that include
Nontraumatic Intracerebral Hemorrhage in Hemisphere Subcortical (spontaneous bleeding within brain
tissue), Acute Respiratory Failure with Hypoxia (sudden inability of lungs to provide adequate oxygen to
blood), and Tracheostomy Status, (surgical procedure that creates an opening in the neck to facilitate
breathing when the usual airway is obstructed or compromised).Review of facility policy titled Tracheostomy
Care, last revised January 2, 2026, revealed compliance guidelines noting the facility will provide necessary
respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy
care and/or suctioning. Review of Resident 2's physician orders failed to reveal orders for oxygen therapy
including method of administration, volume to be administered, or frequency of administration.The policy
further notes that based on the resident's assessment, attending physician orders, and professional
standards of practice, the facility in collaboration with the resident/resident representative will develop a
care plan that includes appropriate interventions for respiratory care. Review of Resident 2's care plan
revealed a focus dated December 24, 2025, noting the resident has a tracheostomy related to impaired
breathing mechanics. Interventions included administer humidified oxygen as prescribed.Further review of
Resident 2's care plan revealed a focus dated December 24, 2025, noting the resident has altered
respiratory status/difficulty breathing related to. No information was provided concerning what Resident 2's
respiratory status/difficulty breathing was related to.Interventions included oxygen (O2) settings: O2 via
(specify nasal prongs/mask) no specifications were noted, at (specify) liters (L), no specifications were
noted, (specify frequency) no specifications were noted, and humidified (specify) no specifications were
noted.Observations of Resident 2 on January 14, 2025, at 10:30 a.m., revealed the resident was receiving
oxygen via the tracheostomy tubing, the oxygen concentrator (a medical device used to filter and
concentrate oxygen obtained from the environment) was set to 6 lpm (liters per minute), and the pressure
pump (device used to supply oxygen under pressure) was set to level 5. Interview with Director of Nursing
(DON) on January 14, 2025, at 11:05 a.m. when the above information was presented, the DON stated the
resident did not have physician orders for oxygen care because the resident was on room oxygen. 28 Pa.
Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395173
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, clinical records review and interview with staff, it was determined that the facility
failed to ensure fluid restriction orders for dialysis residents were followed for one of one dialysis resident
reviewed. (Residents 55). Finding include: A review of the facility's policy titled Fluid Restriction, dated
1/1/26, revealed the following guidelines for restricting fluids: The nurse in collaboration with the dietician
will obtain and verify the physician's order for the fluid restriction and an order written to breakdown include
the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition
department and the nursing department and will be recorded in the medical record. Review of Resident
55's diagnosis list includes End Stage Renal Failure (ESRD- failure of kidney function to remove toxins from
blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose
kidneys are not working normally). Review of Resident physician's orders dated December 16,2025
revealed an order for daily Fluid restriction: 2000ML/day:1000ml dietary, 1000ml nsg. Dietary 420ml
breakfast, 420ml lunch, 180ml dinner. Nursing:420ml 7-3 shift, 460ml 3-11 shift,120ml 11-7 shift. Review of
Resident 55's Medical Administration Record (MAR) failed to reveal evidence of the amount of fluid
Resident 55 was receiving each shift. Interview with Employee 3 on January 13, 2026, at approximately
2:13pm confirmed the above findings. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5)
Nursing Service
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395173
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on facility policy review, observations, and staff interview it was determined the facility failed to label
and store medications in accordance with currently accepted professional principles for 2 out of 3
medication carts reviewed. (1st and 2nd floor back hallway medications carts)Findings include:Review of
facility policy (undated), titled: Medications with Shortened Expiration Dates revealed all eye drops must be
dated upon opening and discarded 3 months after opening unless they have a shortened expiration
date.Observation of the 2nd floor back hall med cart on January 13, 2026 at 9:45 a.m. revealed, Open
Redness Reliever eye drops (saline eye drops) undated open Artificial Tears (saline eye drops) dated
8/26/2025 and open Artificial Tears dated 8/31/2025.A review of the 1st floor back hall medication cart on
January 13, 2026 at 10:00 a.m. was observed to be unlocked and standing out in front of a resident's room
at the end of the hall. When staff came out of the resident's room, they were asked who was responsible for
the med cart. They replied that they were not the nurse on the unit, but they would get the nurse. The staff
proceeded to go up the hallway to the nurses' station to call the nurse. Interview with Licensed Nursing
Employee E6 on January 13, 2026 at 10:05 a.m. revealed that she was assigned to the med cart and
confirmed it was unlocked and the medications were unsecure.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing
Services
Event ID:
Facility ID:
395173
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations and staff interviews, it was determined that the facility failed to properly store food
and maintain sanitary conditions and failed to properly label and date food products in the Main Kitchen
which created the potential for cross contaminationFindings include: During an observation of the main
kitchen on January 11, 2025, at 9:10 a.m. the following was observed: - Dry Storage: three packets of
crackers on the floor, one maple syrup container on the floor, one used rubber glove on the floor, one open
bag of pasta which also lacked proper dating and labeling, and one box containing 24 Glucerna Shakes on
the floor -Walk in freezer- one open bag of chicken patties that was not sealed and missing appropriate
date and label -Walk-in refrigerator- two open bags of bread missing a used by date and label -Prep
refrigerator- one bag of sliced cheese missing appropriate date and label. Interview conducted with the
Kitchen Manager on January 11, 2026, at 9:40 a.m. confirmed that all open bags and containers should
have been properly sealed and contain a used by date and labeled During an interview on January 14,
2025, at 1:15 p.m. Nursing Home Administrator (NHA) confirmed that the facility failed properly store food
and maintain sanitary conditions and properly label and date food products in the main kitchen which
created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c)
Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.
Event ID:
Facility ID:
395173
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview it was determined the facility failed to provide specialized speech
therapy services as determined in their comprehensive care plan for 1 out of 1 resident reviewed. (Resident
29)Findings include:Review of Resident 29's diagnosis list revealed the resident was admitted to the facility
on [DATE] with traumatic hemorrhage of right cerebrum with loss of consciousness (a type of stroke that
causes bleeding in the skull), aphasia (difficulty speaking caused by damage to the brain) and dysphagia
(difficulty swallowing that can be caused by a stroke) and feeding tube (a feeding tube placed in the
stomach) that was placed during her stay in the hospital, and she is receiving 100% nutritional needs
through her feeding tube.Review of Resident 29's care plan dated December 15, 2025 revealed an
intervention of Skilled ST (speech therapy) services as ordered for strengthening and PO (by mouth) trials
to improve oropharyngeal (swallowing) function and ability to tolerate least restrictive diet.Review of
Resident 29's orders revealed an order dated December 15, 2025 for speech therapy 4-5 times per
week.Review of speech therapy records reveal that Resident 29 received an evaluation by an SLP (Speech
Language Pathologist) on December 15, 2025 and received speech therapy on December 17, 2025,
December 19, 2025, and December 21, 2025. Resident 29's next speech therapy session was December
31, 2025.An interview with the E5 (Director of Rehab Services) on January 14, 2026 at approximately
12:15 p.m. revealed the resident should have received therapy on December 24, 2025, but she was
attending a holiday event within the facility, and the speech therapist did not want to interrupt her activity.
Interview with E5 also revealed they did not have a full time SLP on staff because their full time SLP was on
a planned leave and there was a part-time SLP filling in from their corporate office.28 Pa. Code: 211.12
(d)(1)(3)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395173
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehabilitation and Nursing Ctr
2050 Old West Chester Pike
Havertown, PA 19083
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, observation and staff interview, it was determined the facility failed to maintain
accurate and complete clinical records for one out of 8 residents reviewed. (Residents R31)Findings
included:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing,
21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member
of the health-care team by exercising sound judgement based on preparation, knowledge, skills,
understandings, and past experiences in nursing situations. The LPN participates in the planning,
implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of
nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate
records.According to the American Nurses Association Principles for Nursing Documentation, nurses
document their work and outcomes and provide an integrated, real-time method of informing the health
care team about the patient status. Timely documentation of the following types of information should be
made and maintained in a patient's EHR (electronic health record) to support the ability of the health care
team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments
Clinical problems Communications with other health care professionals regarding the patient
Communication with and education of the patient, family, and the patient ' s designated support person and
other third parties. Resident R31 was admitted to the facility on [DATE], with the following diagnosis:
hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke and complete
paralysis of right side), muscle wasting and atrophy, not elsewhere classified, multiple sites, and difficulty in
walking, not elsewhere classified.Review of Resident R31's clinical medical record revealed an active order
for lidocaine pain relief external patch 4 % (lidocaine) apply to right shoulder topically one time a day for
right shoulder pain 12 hours on/12 hours off and remove per schedule. With a start date of January 7,
2025.A review of Resident R31's Medication Administration Record (MAR) revealed the above medication
was documented as administered on January 11, 2025, at 9:00 a.m.However, during an interview
conducted with Resident R31 on January 11, 2025, at 10:23 a.m., the resident stated she refused the
lidocaine pain relief patch because she was not experiencing pain. Observations of Resident R31's right
shoulder at that time confirmed the resident did not have a lidocaine patch in place.An interview conducted
with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 11, 2025, at 1:15
p.m. confirmed that nursing staff inaccurately documented the administration of Resident R31's lidocaine
pain relief patch on the Medication Administration Record (MAR) despite the resident's refusal of the
medication. This documentation error resulted in an inaccurate medical record that failed to accurately
reflect Resident R31's medication administration status. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing
Services28 Pa. Code 211.5 (f) Medical records
Event ID:
Facility ID:
395173
If continuation sheet
Page 9 of 9
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Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 14, 2026 survey of WESTGATE HILLS REHABILITATION AND NURSING CTR?
This was a inspection survey of WESTGATE HILLS REHABILITATION AND NURSING CTR on January 14, 2026. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTGATE HILLS REHABILITATION AND NURSING CTR on January 14, 2026?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep aisles, corridors, and exits free of obstruction in case of emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.