Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
71% occupied
Based on a January 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 24
Capacity: 34
Deficiencies: 7
Jan 9, 2025
Visit Reason
The inspection was a full, unannounced renewal inspection conducted to review compliance with licensing regulations.
Findings
The inspection found multiple deficiencies including incomplete quality management plan content, lack of first aid kits on floors, missing emergency procedure submissions and postings, evacuation drill times exceeding limits, incomplete medical evaluations for residents, and improper medication storage in resident rooms. Plans of correction were accepted and implemented by March 12, 2025.
Deficiencies (7)
| Description |
|---|
| Quality management plan did not address required topics including incident reporting, complaint procedures, staff training, licensing violations, and resident/family councils. |
| First aid kits were not available on either floor. |
| No record of written emergency procedures being sent to the local Emergency Management Agency. |
| Emergency procedures were not posted in a conspicuous and public place in the home. |
| Evacuation drill times exceeded the maximum evacuation time designated by a fire safety expert. |
| Resident medical evaluations were incomplete or missing required information such as body positioning, movement stimulation, evaluation dates, and health status. |
| Medications stored in resident's room were unlocked and unattended, not kept in a safe and secure location. |
Report Facts
License Capacity: 34
Residents Served: 24
Staffing Hours: 25
Waking Staff: 19
Evacuation Drill Time: 294
Evacuation Drill Time: 321
Evacuation Drill Time: 225
Inspection Report
Renewal
Census: 23
Capacity: 34
Deficiencies: 11
Feb 21, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of staff certified in CPR and First Aid during shifts, incomplete fire safety orientation for new staff, incomplete fire drill records, evacuation times exceeding the maximum safe limit, failure to evacuate residents to designated meeting places during fire drills, incomplete medical evaluations for residents, unlocked medications in resident rooms, improper medication storage, missing medications, incomplete medication administration training for staff, and incomplete documentation in resident support plans.
Deficiencies (11)
| Description |
|---|
| No staff persons present in the home were certified in both CPR and First Aid during multiple shifts with 21 to 24 residents present. |
| Staff person did not receive orientation on fire safety and emergency preparedness topics including evacuation procedures, staff duties during fire drills, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and telephone use. |
| Fire drill record did not include the number of residents in the home at the time of the drill. |
| Evacuation time during fire drill exceeded the maximum safe evacuation time of 5 minutes and 30 seconds. |
| Not all residents evacuated to a designated meeting place away from the building or within the fire-safe area during multiple fire drills. |
| Medical evaluation for Resident #1 was not completed within 60 days prior to admission or within 30 days after admission. |
| Resident #2's room was unlocked and two containers of prescribed medications were on top of the resident's nightstand; resident was not in the room at the time. |
| Resident #1 had medication requiring refrigeration stored improperly in the medication cart. |
| Medications prescribed for Resident #2 and Resident #3 were not available in the home on the date of inspection. |
| Staff persons administered medications without completing the Department-approved medication administration course within the required timeframe. |
| Resident #1 had an enabler on their bed but the current assessment and support plan did not indicate a need for the enabler. |
Report Facts
Residents served: 23
License capacity: 34
Evacuation time: 381
Staff total daily: 23
Waking staff: 17
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 1, 2022
Visit Reason
The visit was conducted to review the submitted plan of correction for the facility.
Findings
The Pennsylvania Department of Human Services determined that the submitted plan of correction is fully implemented and that continued compliance must be maintained.
Document
Capacity: 34
Deficiencies: 0
May 21, 2021
Visit Reason
The document includes a Certificate of Compliance granting Westminster Woods permission to operate a Personal Care Home with a maximum capacity of 34 residents, and a letter acknowledging receipt of a renewal application with notice of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported; the documents confirm licensing compliance and outline the requirement for an annual inspection to be conducted within the next year.
Report Facts
Maximum licensed capacity: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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