Inspection Report
Monitoring
Census: 44
Capacity: 79
Deficiencies: 6
Apr 9, 2025
Visit Reason
The inspection was an unannounced partial review conducted for monitoring purposes to verify the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to treat residents with dignity and respect, unqualified direct care staff, unsanitary conditions, presence of discontinued medications in the medication cart, unlabeled resident medications, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Deficiencies (6)
| Description |
|---|
| Resident left sitting alone for extended periods without assistance, resulting in distress and soiling. |
| Direct care staff person does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Unsanitary condition found: a white washcloth covered in a dark brown, foul smelling substance on the shower floor of a resident's bathroom. |
| Discontinued medications were found in the residence's medication cart. |
| Resident medication lacked a pharmacy label matching the prescribed order. |
| Medication prescribed to a resident was not administered on specified dates due to unavailability in the residence. |
Report Facts
Residents served: 44
License capacity: 79
Total daily staff: 56
Waking staff: 42
Current hospice residents: 8
Residents 60 years or older: 44
Residents with mobility need: 12
Residents with physical disability: 1
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 3
Mar 14, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
The inspection found deficiencies related to medication administration errors, failure to follow prescriber orders, and incomplete resident support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Complaint Details
The inspection was triggered by a complaint and incident. The submitted plan of correction was reviewed and found fully implemented on 03/14/2025.
Deficiencies (3)
| Description |
|---|
| Prescription medications were administered to a resident other than the one for whom they were prescribed. |
| The home failed to follow the directions of the prescriber regarding medication administration. |
| Resident support plan did not include the use of a fall mat next to the bed as required. |
Report Facts
License Capacity: 79
Residents Served: 46
Current Hospice Residents: 8
Residents Age 60 or Older: 46
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Total Daily Staff: 60
Waking Staff: 45
Inspection Report
Complaint Investigation
Census: 48
Capacity: 79
Deficiencies: 36
Nov 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of mistreatment or abuse of residents and failure to comply with plans to correct noncompliance items.
Findings
Multiple deficiencies were found including failure to provide timely assistance with ADLs, failure to report incidents and abuse timely, inadequate staffing during certain shifts, failure to follow prescriber's orders, lack of proper staff qualifications and training, and failure to maintain sanitary conditions. Several complaints were not properly investigated or resolved.
Complaint Details
The visit was complaint-related due to allegations of mistreatment or abuse of residents, failure to comply with plans of correction, and multiple family complaints regarding resident care. Several complaints were not properly investigated or resolved, and status reports and written decisions were not timely provided to complainants and designated persons.
Deficiencies (36)
| Description |
|---|
| Delayed provision of requested staff member list to Department agents. |
| Failure to report an assault incident to the Department within 24 hours. |
| Failure to provide assistance with ADLs as indicated in resident assessments and support plans. |
| Resident neglected by not administering prescribed medication due to lack of qualified staff. |
| Unsafe wheelchair transport causing resident fall and injury. |
| Failure to position resident's wedge pillow to prevent falls, resulting in resident fall. |
| Staff member without completed criminal background check. |
| Emergency telephone numbers not posted by telephone in resident room. |
| Failure to follow prescriber's orders for medication administration and medical devices. |
| Resident support plans not signed by residents. |
| Failure to provide immediate access to requested documents to Department agents. |
| Resident abuse incident involving staff member sharing video of resident's condition without consent. |
| Failure to immediately notify resident and designated person of suspected abuse report. |
| Failure to report incidents to Department within 24 hours as required. |
| Failure to provide assistance with ADLs in a timely manner, including delayed response to call bells. |
| Failure to provide assistance with personal hygiene as indicated in resident support plans. |
| Resident neglected, intimidated, or verbally abused by staff. |
| Residents not treated with dignity and respect, including delayed assistance and inappropriate staff behavior. |
| Violation of resident privacy by staff sharing video of resident's condition and inappropriate signage for video surveillance. |
| Failure to investigate and resolve multiple resident complaints and failure to designate staff responsible for complaint resolution. |
| Failure to provide status reports within 2 business days after written complaints. |
| Failure to provide written decision within 7 days after written complaints explaining investigation findings and actions. |
| Direct care staff lacking required qualifications such as high school diploma, GED, or nurse aide registry status. |
| Staffing levels inadequate to meet resident needs during certain overnight shifts. |
| Insufficient staff trained in first aid and CPR present during certain shifts. |
| Direct care staff did not receive required orientation in fire safety and emergency preparedness on first work day. |
| Direct care staff did not receive initial orientation on job duties. |
| Direct care staff did not complete required orientation training within 40 scheduled working hours. |
| Direct care staff did not complete required 18 hours of initial direct care training. |
| Administrative and direct care staff did not receive required dementia-specific training within 30 days of hire. |
| Poisonous materials were unlocked and accessible to residents, including those not assessed as safe to use or avoid poisons. |
| Resident's bed linens soiled with urine and feces and not changed promptly. |
| Unannounced fire drill not held during December 2024. |
| Fire drill during sleeping hours not held within required 6 month period. |
| Medication administration record showed medications administered when they were not available in the residence. |
| Failure to follow prescriber's orders for medication administration resulting in missed doses. |
Report Facts
License Capacity: 79
Residents Served: 48
Staffing Hours: 71
Waking Staff: 53
Fine Amount: 245
Fine Per Resident Per Day: 5
Census at Violation: 49
Call Bell Wait Times (minutes): 140
Inspection Report
Complaint Investigation
Census: 48
Capacity: 79
Deficiencies: 27
Nov 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of mistreatment, abuse, and failure to comply with plans to correct noncompliance items at Westlake Woods AL.
Findings
Multiple violations were found including failure to provide timely assistance with ADLs, failure to report incidents and abuse promptly, inadequate staffing levels, failure to follow prescriber's orders, lack of proper staff qualifications and training, unsafe storage of poisonous materials, and failure to maintain sanitary conditions. Several complaints by residents' families were not properly investigated or resolved.
Complaint Details
The complaint investigation was triggered by multiple family complaints regarding mistreatment, abuse, inadequate care, and failure to follow regulations. The facility failed to promptly report abuse, investigate complaints, provide status reports, and issue written decisions. Several complaints involved residents #2, #3, #5, #6, and #7.
Deficiencies (27)
| Description |
|---|
| Failure to provide immediate access to requested staff member list. |
| Failure to report an assault incident to the department within 24 hours. |
| Failure to assist residents with ADLs as indicated in their support plans, including dressing and hearing aid charging. |
| Resident neglect and abuse including medication non-administration and unsafe transport resulting in resident injury. |
| Failure to complete criminal background checks for staff. |
| Lack of emergency telephone numbers posted by resident telephones. |
| Failure to follow prescriber's medication orders resulting in missed medications. |
| Resident support plans not signed by residents. |
| Failure to provide timely assistance with toileting and call bell response delays up to over 2 hours. |
| Failure to treat residents with dignity and respect, including staff verbal abuse and serving cold food. |
| Unsanitary conditions including feces found in resident shower. |
| Failure to report suspected abuse immediately and notify resident and designated person. |
| Failure to investigate and resolve multiple family complaints and designate staff responsible for complaint outcomes. |
| Failure to provide status reports and written decisions regarding complaints within required timeframes. |
| Direct care staff lacking required qualifications including high school diploma or nurse aide registry status. |
| Inadequate staffing levels during night shifts to meet residents' needs and emergency evacuation requirements. |
| Insufficient staff trained in first aid and CPR present during shifts. |
| Direct care staff did not receive required orientation on fire safety and emergency preparedness on first work day. |
| Direct care staff did not receive initial orientation on job duties. |
| Direct care staff did not complete required 40-hour orientation training including resident rights and abuse reporting. |
| Direct care staff did not complete required 18 hours of initial direct care training. |
| Direct care staff did not receive dementia-specific training within 30 days of hire. |
| Poisonous materials were left unlocked and accessible to residents. |
| Resident bed linens were found soiled with urine and feces. |
| Unannounced fire drill was not held during December 2024. |
| Fire drill during sleeping hours was not conducted within required 6-month period. |
| Medication administration records indicated medications were given when they were not available and not administered. |
Report Facts
License Capacity: 79
Residents Served: 48
Staffing Hours: 71
Waking Staff: 53
Number of Residents with Mobility Need: 23
Number of Residents with Physical Disability: 2
Fine Amount: 245
Inspection Dates: 7
Residents Served: 50
Residents Served: 49
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Staff Present: 1
Residents Present: 48
Inspection Report
Complaint Investigation
Census: 48
Capacity: 79
Deficiencies: 21
Nov 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of mistreatment or abuse of residents, failure to comply with plans to correct noncompliance items, and other regulatory concerns at Westlake Woods AL.
Findings
Multiple violations were found including failure to provide timely assistance with ADLs, failure to report incidents and abuse timely, inadequate staffing levels, failure to follow prescriber's orders, lack of proper staff qualifications and training, failure to maintain sanitary conditions, and failure to investigate and resolve complaints. Several residents experienced neglect, abuse, and dignity violations.
Complaint Details
The complaint investigation was substantiated with findings of mistreatment, abuse, neglect, failure to report incidents timely, inadequate staffing, and failure to follow regulatory requirements. Multiple family complaints were investigated with resolutions communicated.
Deficiencies (21)
| Description |
|---|
| Failure to provide immediate access to requested staff records. |
| Failure to report an assault incident to the department within 24 hours. |
| Failure to provide assistance with ADLs as indicated in resident assessments and support plans. |
| Resident neglect and abuse including failure to administer medications and unsafe resident transport. |
| Failure to complete criminal background checks for staff. |
| Emergency telephone numbers not posted by resident telephones. |
| Failure to follow prescriber's orders including medication administration. |
| Resident support plans not signed by residents. |
| Failure to maintain sanitary conditions including feces found in resident shower. |
| Failure to report suspected abuse immediately and notify resident and designated person. |
| Failure to investigate and resolve complaints and designate responsible staff. |
| Failure to provide status reports and written decisions on complaints within required timeframes. |
| Direct care staff lacked required qualifications including high school diploma or nurse aide registry status. |
| Staffing levels inadequate to meet resident needs during certain shifts. |
| Insufficient staff trained in first aid and CPR present during shifts. |
| Direct care staff did not receive required orientation and training on fire safety, job duties, resident rights, abuse reporting, and core competencies. |
| Poisonous materials were not locked and accessible to residents who are not assessed as safe to use or avoid them. |
| Resident bed linens soiled with urine and feces. |
| Unannounced fire drill not held during December 2024 and no fire drill during sleeping hours within required timeframe. |
| Medication administration records showed medications administered when they were not available in the residence. |
| Failure to follow prescriber's orders with multiple missed medication administrations. |
Report Facts
License Capacity: 79
Residents Served: 48
Staffing: 71
Waking Staff: 53
Fine Amount: 245
Correction Date: 5
Residents with Mobility Need: 23
Residents with Physical Disability: 2
Residents Served: 50
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Total Daily Staff: 65
Waking Staff: 49
Residents Served: 49
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Total Daily Staff: 60
Waking Staff: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple findings including failure to report abuse, neglect, failure to follow prescriber orders, lack of training, and inappropriate conduct during care. | |
| Staff person B | Witnessed abuse incident and reported it; involved in abuse and neglect findings. | |
| Staff person C | Witnessed abuse incident and involved in abuse and neglect findings. | |
| Staff person E | Named in findings for lack of qualifications, training, and orientation. | |
| Staff person F | Named in findings for lack of qualifications, training, and orientation. | |
| Staff person H | Named in findings for lack of orientation and dementia training. | |
| Executive Director | Named as responsible for implementing corrective actions, training, audits, and compliance monitoring. | |
| Care Team Manager | Named as responsible for audits, training, and monitoring compliance. | |
| Environmental Services Manager | Named as responsible for training housekeeping staff and conducting fire drills. | |
| Operations Specialist | Named as responsible for training leadership and maintaining fire drill schedules. | |
| Health and Wellness Director | Named as responsible for medication administration training and audits. | |
| Area Director of Operations | Named as responsible for reviewing grievance logs and compliance. | |
| Area Director of Clinical Services | Conducted medication administration training. |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 79
Deficiencies: 4
Apr 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
Multiple deficiencies were found including unsanitary conditions in a resident's apartment, missing medications, failure to document and report medication refusals, and failure to follow prescriber orders. Plans of correction were submitted and later determined to be fully implemented.
Complaint Details
The visit was complaint-related, triggered by a complaint received by the licensing authority. The complaint involved concerns about sanitary conditions and medication management.
Deficiencies (4)
| Description |
|---|
| Multiple heavily soiled smears of fecal matter and urine stains were found on resident #1's bed and floor, indicating unsanitary conditions. |
| Medications prescribed for resident #2 were not present in the home at one point, indicating failure in safe storage and availability of medications. |
| Resident #3 refused medication multiple times but the home failed to immediately notify the prescribing physician as required. |
| Resident #2 and resident #4 were not administered prescribed medications on certain occasions because the medications were not present in the home, indicating failure to follow prescriber orders. |
Report Facts
Residents Served: 59
License Capacity: 79
Total Daily Staff: 82
Waking Staff: 62
Residents Diagnosed with Mental Illness: 3
Residents Aged 60 or Older: 59
Residents with Mobility Need: 23
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 48
Capacity: 79
Deficiencies: 6
Sep 28, 2023
Visit Reason
The inspection was an unannounced partial complaint investigation conducted due to a complaint indicator.
Findings
The inspection identified multiple deficiencies including failure to report medication errors, inadequate assistance with activities of daily living (ADLs), insufficient staffing during overnight hours, medication storage and documentation issues, and failure to follow prescriber orders. Plans of correction were submitted and later determined to be fully implemented.
Complaint Details
The visit was complaint-related, triggered by a complaint indicator. The complaint involved medication errors, failure to report incidents, inadequate ADL assistance, and staffing concerns. The complaint was substantiated with multiple deficiencies found.
Deficiencies (6)
| Description |
|---|
| Failure to report a medication error involving administration of medication to the wrong resident. |
| Resident did not receive assistance with showering as indicated in the resident’s assessment and support plan. |
| Inadequate staffing during overnight hours to safely evacuate residents, especially those with mobility needs. |
| Medications were not available in the home and medication administration was not properly documented. |
| Failure to follow prescriber’s orders for medication administration. |
| Medication error was not immediately reported to the resident, designated person, and prescriber as required. |
Report Facts
License Capacity: 79
Residents Served: 48
Total Daily Staff: 71
Waking Staff: 53
Residents with Mobility Need: 23
Staff on Duty Overnight: 3
Fire Drill Evacuation Time: 18
Inspection Report
Complaint Investigation
Census: 53
Capacity: 79
Deficiencies: 1
May 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/09/2023 and 05/10/2023.
Findings
The facility was found to have staffing deficiencies related to meeting residents' needs for emergency evacuation assistance, with insufficient direct care staff during certain shifts. A plan of correction was submitted and later determined to be fully implemented.
Complaint Details
The inspection was complaint-driven and included a follow-up on the plan of correction submission. The plan of correction was accepted and fully implemented as of 11/15/2023.
Deficiencies (1)
| Description |
|---|
| On 4/23/23 and 5/6/23, there were insufficient direct care staff to assist residents with mobility needs during emergency evacuations, with only 2 staff working during critical overnight hours. |
Report Facts
License Capacity: 79
Residents Served: 53
Residents with mobility needs: 23
Direct care staff: 2
Staffing hours: 76
Waking staff: 57
Residents evacuated in fire drill: 45
Staff participated in fire drill: 3
Inspection Report
Renewal
Census: 50
Capacity: 79
Deficiencies: 6
Mar 30, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with an unannounced full inspection on 03/30/2023 and an exit conference on 04/03/2023.
Findings
The inspection identified multiple deficiencies including failure to update resident-residence contracts after a change of legal entity, direct care staff qualification issues, cleanliness and maintenance concerns such as stains on carpet, combustible storage near heat sources, failure to conduct a monthly fire drill, and incomplete medical evaluations for residents. Plans of correction were submitted and accepted with implementation dates noted.
Deficiencies (6)
| Description |
|---|
| Resident-residence contracts were not updated to reflect the change of legal entity for multiple residents. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Multiple stains on the living room carpet in apartment #219. |
| Combustible paperwork was located on top of the furnace in the furnace room. |
| An unannounced fire drill was not held during the month of March 2023. |
| Medical evaluation for resident #3 was incomplete or outdated. |
Report Facts
License Capacity: 79
Residents Served: 50
Current Hospice Residents: 3
Staffing Hours: 73
Waking Staff: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct care staff person | Named in finding for lacking required qualifications. |
| Environmental Services Manager | Named in findings related to combustible storage and housekeeping. | |
| Health and Wellness Director | Named in relation to medical evaluation compliance and audits. |
Inspection Report
Census: 60
Capacity: 79
Deficiencies: 0
Dec 27, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 87
Waking Staff: 65
Residents Served: 60
License Capacity: 79
Current Hospice Residents: 1
Residents Age 60 or Older: 60
Residents with Mobility Need: 27
Inspection Report
Follow-Up
Census: 57
Capacity: 79
Deficiencies: 5
Dec 5, 2022
Visit Reason
The inspection visit was a partial, unannounced review triggered by an incident to assess compliance with regulatory requirements and to verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple violations related to resident abuse reporting, resident abuse supervision plans, incident reporting, abuse/neglect, and direct care staff qualifications. The facility was found to have delayed reporting suspected abuse incidents and employed a direct care staff person without proper qualifications. Plans of correction were submitted and accepted, with full implementation confirmed by August 4, 2023.
Complaint Details
The visit was related to an incident complaint involving allegations of resident abuse by staff person A. The allegations included forceful physical and verbal abuse of residents, which were not reported timely to the local Area Agency on Aging or the Department. The Executive Director notified the Area Agency on Aging immediately upon receipt of the allegations and conducted retraining and monitoring to ensure compliance.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of residents as required by law. |
| Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse incidents. |
| Failure to report incidents or conditions to the Department's assisted living residence office within 24 hours as required. |
| Resident abuse and neglect including forceful handling, verbal abuse, and physical mistreatment by staff person A. |
| Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
License Capacity: 79
Residents Served: 57
Current Hospice Residents: 3
Total Daily Staff: 85
Waking Staff: 64
Residents with Mobility Need: 28
Residents Age 60 or Older: 57
Inspection Report
Re-Inspection
Census: 53
Capacity: 79
Deficiencies: 0
Sep 26, 2022
Visit Reason
The inspection was conducted due to a change in the legal entity operating the assisted living facility, Westlake Woods AL, as part of licensing requirements.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection because this is a new legal entity. No deficiencies were found during this partial inspection.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 79
Waking Staff: 59
Residents Served: 53
License Capacity: 79
Current Residents in Hospice: 4
Residents 60 Years of Age or Older: 53
Residents with Mobility Need: 26
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