Inspection Reports for
Westminster Place of Oakmont
1215 HULTON ROAD,, OAKMONT, PA, 15139
Back to Facility Profile27 Reports
Inspection Report — Nov 20, 2025
Complaint Investigation
Date: Nov 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 11/20/2025.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The plan of correction was fully implemented and accepted.
Findings
The facility was found non-compliant with Regulation 2600.94(b) due to the absence of nonskid surfaces on exterior wooden steps and ramp. The facility implemented corrective actions including repainting with nonskid coating and staff education, achieving full compliance by 12/02/2025.
Citations (1)
Regulation 2600.94(b) requires nonskid surfaces on interior stairs, exterior steps, and ramps. The exterior wooden steps and ramp leading from the dining room emergency exit to the courtyard lacked nonskid surfaces at the time of inspection.
Report Facts
Residents Served: 75
Current Residents in Hospice: 7
Inspection Report — Sep 29, 2025
Plan of Correction
Date: Sep 29, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident involving resident abuse.
Findings
The report details multiple incidents of resident-to-resident abuse involving physical altercations causing injuries, including a skin tear and bite mark. The facility took corrective actions including separating residents, involving crisis center consultations, hiring private sitters, and implementing medication and safety plans. A 30-day written notice was served to relocate the residents involved due to ongoing violent disruptions.
Citations (1)
Resident abuse incidents involving physical harm between residents, including hitting with a cane and biting.
Report Facts
Residents Served: 73
Current Residents in Hospice: 7
Residents Age 60 or Older: 73
Residents with Mental Illness: 1
Residents with Mobility Need: 14
Residents with Intellectual Disability: 0
Residents with Physical Disability: 0
Staff Total Daily: 87
Staff Waking: 65
Inspection Report — Sep 3, 2025
Renewal
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at Westminster Place of Oakmont.
Complaint Details
The inspection included a complaint investigation component as indicated by the inspection reason 'Renewal, Complaint'. Specific substantiation status is not stated.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, maintenance issues such as rusted vent covers, improper food storage, unsecured medications, incorrect medication labeling, and use of correction fluid on resident records. All deficiencies had plans of correction accepted and were reported as fully implemented by the follow-up date.
Citations (7)
Resident-home contracts for residents #1 and #2 were not signed by the residents.
Rusted and peeling paint on air conditioning vent cover in resident room #212.
Open and unsealed bag of frozen French toast found in freezer.
Multiple unlabeled and undated frozen food items found in freezer, including frozen waffles and French toast.
Prescription and OTC medications found unlocked, unattended, and accessible in resident rooms #1, #2, #4, and #5, with residents unable to self-administer.
Pharmacy labels for medications of residents #5 and #6 did not match prescribed instructions.
Correction fluid used on resident records for residents #1, #6, and #7 in various sections.
Report Facts
Residents Served: 76
Current Hospice Residents: 7
Residents with Mobility Need: 12
Residents Diagnosed with Mental Illness: 1
Total Daily Staff: 88
Waking Staff: 66
Inspection Report — Jan 8, 2025
Follow-Up
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was found to be fully implemented, with staff retraining on resident rights and abuse completed, and the involved staff member terminated. Resident interviews confirmed no new concerns and feelings of safety.
Citations (1)
A resident was intimidated and felt unsafe when a staff member aggressively took away the resident's call bell pendant for approximately 45 minutes, violating resident rights and abuse prevention policies.
Report Facts
Residents Served: 71
Current Hospice Residents: 7
Staffing Hours - Total Daily Staff: 83
Staffing Hours - Waking Staff: 62
Residents Who Receive Supplemental Security Income: 1
Residents Who Are 60 Years of Age or Older: 71
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents Who Have Mobility Need: 12
Residents Who Have Physical Disability: 0
Inspection Report — Aug 8, 2024
Date: Aug 8, 2024
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 73
Waking Staff: 55
Residents Served: 66
Current Hospice Residents: 4
Residents Age 60 or Older: 66
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Westminster Place of Oakmont on 03/14/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Report Facts
Residents Served: 73
Current Hospice Residents: 4
Total Daily Staff: 77
Waking Staff: 58
Resident Support Staff: 0
Inspection Report — Jan 18, 2024
Follow-Up
Date: Jan 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have multiple deficiencies related to staff qualifications, orientation, medication storage and administration, and adherence to medication policies. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Citations (6)
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staff person did not receive required orientation on fire safety and emergency preparedness topics on their first day.
Prescription medications and syringes were not kept locked; a bottle of spray was found unlocked and unattended on a resident's bedside table.
Failure to follow proper procedures for medication cart shift exchange and narcotic counts, including unsecured med cart keys and missing signatures on count logs; unmarked medications were found replacing resident medications without proper reporting to law enforcement.
Medication prescribed to a resident was not available in the home; staff obtained medication from the skilled nursing facility stock, which is not permitted.
Medications prescribed to a resident were not administered because staff was unable to locate them in the home; this was a repeat violation.
Report Facts
Residents Served: 75
Current Hospice Residents: 3
Total Daily Staff: 78
Waking Staff: 59
Number of times staff person A did not sign on/off shift count logs: 14
Number of unmarked tablets replaced for resident: 3
Number of unmarked tablets replaced for another resident: 2
Inspection Report — Oct 19, 2023
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility on 10/19/2023.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 73
Current Hospice Residents: 5
Resident Support Staff: 81
Waking Staff: 61
Residents Age 60 or Older: 73
Residents with Mobility Need: 8
Inspection Report — Apr 27, 2023
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
Current Hospice Residents: 2
Residents Age 60 or Older: 73
Residents with Mobility Need: 3
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Sep 26, 2022
Follow-Up
Date: Sep 26, 2022
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction related to medication administration and abuse policies.
Findings
The facility was found to have fully implemented the plan of correction addressing medication administration errors, including incorrect dosages and labeling discrepancies, as well as abuse policy education. Continued compliance was required and ongoing medication audits were planned.
Citations (4)
Resident #3 was administered 20 times the prescribed dosage of medication due to a medication administration error.
Resident #1 had discontinued medication stored in the medication cart.
Resident #2 had expired and undated medications stored in the medication cart.
Resident #2's medication label indicated incorrect dosage frequency compared to the prescription.
Report Facts
Residents Served: 69
Total Daily Staff: 72
Waking Staff: 54
Inspection Report — May 18, 2022
Renewal
Date: May 18, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple deficiencies including failure to complete direct care training before unsupervised care, hot water temperatures exceeding 120°F in multiple locations, furniture and equipment hazards, inadequate bedside lighting, outdated prescription medication, and improper storage procedures for medical equipment. Plans of correction were accepted and fully implemented.
Citations (6)
Direct care staff person provided unsupervised care before completing Department-approved direct care training and competency test.
Hot water temperature exceeded 120°F in four separate locations during inspection.
Resident's handheld showerhead did not rest snugly in cradle, allowing it to fall freely.
Resident was unable to reach lamp or other operable source of light from bedside.
Discontinued medication was found in medication strip packaging delivered after discontinuation date.
Resident's glucometer time reading was off by 4 hours, indicating improper storage procedures.
Report Facts
Residents Served: 69
Hot Water Temperature: 127.8
Hot Water Temperature: 124.5
Hot Water Temperature: 125
Hot Water Temperature: 124.8
Hot Water Temperature: 131.2
Inspection Report — Mar 2, 2022
Routine
Date: Mar 2, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Nov 1, 2021
Follow-Up
Date: Nov 1, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted on 11/01/2021 to review the facility's compliance following an incident and plan of correction submission.
Complaint Details
An allegation of abuse was made against staff person A involving resident #1 on 10/19/21. The staff person continued to work without a plan of supervision being submitted to the Department. The staff person was later removed from schedule pending investigation.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a supervision violation involving an allegation of abuse against a staff member. Continued compliance was required.
Citations (1)
Failure to immediately submit a plan of supervision or notice of suspension of the affected staff person following an allegation of abuse.
Report Facts
Residents Served: 78
Current Hospice Residents: 5
Residents with Mobility Need: 4
Inspection Report — Jul 12, 2021
Follow-Up
Date: Jul 12, 2021
Visit Reason
The inspection was a full, unannounced review conducted on 07/12/2021 and 07/13/2021 as a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the plan of correction fully, addressing multiple deficiencies including record confidentiality, resident personal equipment safety, poisonous materials storage, emergency telephone numbers posting, unobstructed egress, medication labeling and storage, medication record keeping, and preadmission screening documentation. Continued compliance and monitoring were emphasized.
Citations (9)
Resident records were found unlocked and unattended containing personal information and narcotic logs.
Bed enablers for residents #7 and #8 posed possible entrapment hazards due to improper positioning and cover openings.
An unlabeled spray bottle with unknown pink liquid was found stored improperly.
Emergency telephone numbers were missing on or by the telephone on resident #10's dresser.
A metal chain blocked the egress route from the home's front porch to the steps.
Resident #11's inhaler lacked a pharmacy label and medication orders had inconsistencies.
Resident #11's prescribed Oxycodone 5mg was not available in the home for administration on 7/13/21.
Medication administration records (MAR) for residents #11 and #12 lacked staff initials for administered medications on multiple dates.
Resident #13's preadmission screening did not indicate if the resident can safely use and avoid poisonous materials.
Report Facts
Residents Served: 80
Total Daily Staff: 85
Waking Staff: 64
Current Residents on Hospice: 4
Residents Age 60 or Older: 80
Residents with Mobility Need: 5
Notice — Jun 15, 2021
Date: Jun 15, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Westminster Place of Oakmont, a Personal Care Home, following receipt of the renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and outlines the Department's obligation to conduct an annual inspection and take enforcement action if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Apr 7, 2020
Routine
Date: Apr 7, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Westminster Place of Oakmont to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Mar 11, 2020
Date: Mar 11, 2020
Visit Reason
This document is a renewal notification and certificate of compliance for Westminster Place of Oakmont, confirming the facility's licensed capacity and renewal of its Personal Care Home license.
Findings
The Department of Human Services has received the renewal application and issued a regular license. The Department will conduct an onsite annual inspection within the next twelve months as required by regulation.
Inspection Report — Dec 18, 2019
Renewal
Date: Dec 18, 2019
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Westminster Place of Oakmont.
Findings
The inspection identified multiple violations including incomplete annual training for ancillary staff, prohibited use of portable space heaters, cigarette butts found outside the designated smoking area, and medication management issues involving resident ointments and prescriptions. Plans of correction were implemented and approved.
Citations (6)
Ancillary staff member did not complete required annual training in emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during 2018.
A portable space heater was found in a resident's bedroom, which is prohibited; the heater was removed and staff educated on the prohibition.
Approximately 10 cigarette butts were found outside the ground floor exit door, outside the designated smoking area; the area was cleaned and staff reminded of smoking policies.
Preparation H ointment was present in a resident's bathroom without assessment by a qualified medical professional regarding self-administration ability and medication reminders.
An expired bottle of Miralax was found in a resident's bathroom and removed; the resident reported the family brought it but it was not needed or prescribed.
Resident medication for Carvedilol 6.25 mg was not taken with meals as prescribed; pharmacy label was corrected and nursing updated physician orders accordingly.
Report Facts
Residents Served: 87
Current Hospice Residents: 4
Diagnosed with Mental Illness: 1
Diagnosed with Intellectual Disability: 1
Have Mobility Need: 2
Are 60 Years of Age or Older: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Hammar | Administrator | Named in relation to plan of correction approvals and survey findings |
Inspection Report — Sep 23, 2019
Routine
Date: Sep 23, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Westminster Place of Oakmont on September 23, 2019.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Williams | Human Services Licensing Supervisor | Signed the inspection report letter. |
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Westminster Place of Oakmont to operate as a Personal Care Home under Pennsylvania regulations.
Findings
The Department of Human Services has approved the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months as required by state code.
Inspection Report — Dec 18, 2018
Renewal
Date: Dec 18, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Westminster Place of Oakmont under 55 Pa. Code Chapter 2600.
Findings
The inspection identified violations related to fire drill documentation and resident support plan signatures. Plans of correction were submitted and approved to address these issues.
Citations (2)
Regulation 55 Pa.Code §2600.132(c): The fire drill record for 1/3/18 incorrectly documented the number of residents evacuated. Only 8 residents were evacuated, but the record indicated otherwise.
Regulation 55 Pa.Code §2600.227(h): Resident #1's support plan dated 8/1/18 and Resident #2's support plan dated 6/17/18 were not signed by the residents and did not indicate if the residents were unable or refused to sign.
Report Facts
Number of Residents Served: 87
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 10
Number of Residents Present at Fire Drill: 93
Number of Residents Evacuated at Fire Drill: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Hammar | Administrator | Named as Administrator and signed legal entity representative on pages 2, 3, and 4. |
| Lauren Spagna | On-site inspector for the inspection on 12/18/2018 as listed on page 2. | |
| Laurie Garrigan | On-site inspector for the inspection on 12/18/2018 as listed on page 2. | |
| Cindy Mulick | On-site inspector for the inspection on 12/18/2018 as listed on page 2. |
Notice — Apr 6, 2018
Date: Apr 6, 2018
Visit Reason
This document serves as a renewal approval notice for the Personal Care Home license of Westminster Place of Oakmont and informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Jan 8, 2018
Renewal
Date: Jan 8, 2018
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspection and renewal of the Personal Care Home license for Westminster Place of Oakmont.
Findings
Multiple violations related to sanitary conditions, bathroom ventilation, food refrigeration, medication management, and equipment calibration were identified. Plans of correction were submitted and partially implemented with ongoing monitoring.
Citations (6)
Regulation 2600.85(a) sanitary conditions were not maintained as glucometers were shared among residents without proper labeling and sanitation.
Regulation 2600.86(b) a bathroom attached to bedroom #106 lacked an operable exhaust fan and outside window for ventilation.
Regulation 2600.103(f) food requiring refrigeration was stored above 40°F in the freezer labeled 'Gluten Free'.
Regulation 2600.183(d) discontinued medications were present on the medication cart instead of only current prescriptions and OTCs.
Regulation 2600.184(a) the original container for prescription medications lacked a complete sliding scale for insulin administration.
Regulation 2600.185(a) glucometers for residents #3, #6, and #7 were not calibrated to the correct date and time.
Report Facts
Number of Residents Served: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Hamman | Administrator | Named as legal entity representative and signer of plans of correction. |
Notice — Mar 7, 2017
Date: Mar 7, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Westminster Place of Oakmont, confirming receipt of the renewal application and outlining the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms that a regular license is being issued in response to the renewal application.
Inspection Report — Feb 9, 2017
Renewal
Date: Feb 9, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Westminster Place of Oakmont.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 after corrections were made. Two violations were identified related to uncovered trash receptacles and incomplete initial resident assessments, both of which were fully corrected by the time of the report.
Citations (2)
55 Pa.Code §2600.85(d) - Trash in kitchens and bathrooms shall be kept in covered trash receptacles that prevent the penetration of insects and rodents. An uncovered trashcan in bathroom #319A was observed during the inspection.
55 Pa.Code §2600.225(a) - A resident shall have a written initial assessment documented within 15 days of admission. Resident #1's initial assessment was misdated and not completed within the required timeframe.
Report Facts
Number of Residents Served: 90
Total Daily Staff: 92
Walking Staff: 69
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 4
Number of Residents 60 Years or Older: 90
Number of Residents with Mental Illness: 4
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Hammar | Administrator | Named in relation to the plan of correction for violations. |
Notice — Apr 20, 2016
Date: Apr 20, 2016
Visit Reason
The document serves as a notice of a revised licensed capacity for Westminster Place of Oakmont due to a recent adjustment in the use of physical space at the facility.
Findings
The revised license indicates a reduction in the maximum number of persons the facility may care for at one time to 120. The expiration date of the license remains unchanged.
Report Facts
Inspection Report — Apr 12, 2016
Renewal
Date: Apr 12, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on April 12 and 13, 2016, for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including deficiencies in staff first aid certification, hot water temperature, furniture safety, emergency procedures, egress routes, medication labeling, and medication administration. Plans of correction were initiated for each violation.
Citations (7)
55 Pa.Code §2600.83(a) - Only one staff person was certified in first aid during the inspection, though four staff were present. At least one staff person per 50 residents must be trained and certified in first aid at all times.
55 Pa.Code §2600.89(b) - Hot water temperature at the third floor north kitchenette sink measured 123°F, exceeding the 120°F maximum allowed.
55 Pa.Code §2600.95 - The unsecured steam table in the kitchen area reached 179°F without protective guards, posing a hazard to residents.
55 Pa.Code §2600.107(b) - The home's emergency management procedures lacked telephone numbers for state and local emergency management agencies.
55 Pa.Code §2600.121(a) - A wheeled bookcase blocked emergency egress in the Atrium/Chapel area, obstructing exit routes.
55 Pa.Code §2600.184(a) - The pharmacy label for resident #3's insulin did not match the medication administration record, risking medication errors.
55 Pa.Code §2600.187(d) - Resident #4's Budesonide nebulizer medication was unavailable and not administered as ordered on multiple dates.
Report Facts
Number of Residents Present: 83
Total Daily Staff: 92
Waking Staff: 89
Hot Water Temperature: 123
Steam Table Temperature: 179
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Hammer | Administrator | Signed multiple violation reports and plans of correction. |
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