Pennsylvania Department of Health
WHITEHALL BOROUGH POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WHITEHALL BOROUGH POST ACUTE
Inspection Results For:

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WHITEHALL BOROUGH POST ACUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure , Civil Rights Compliance, and an Abbreviated survey in response to three complaints completed on May 7, 2026, it was determined that Whitehall Borough Post Acute was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 06/23/2026

Resident (R3) Provider reviewed blood sugars and due to residents' non-compliance, she will document to liberalize notification to physician to greater than 450. Sliding scale was also updated. Resident (R64) Provider has been monitoring blood sugars closely, has made insulin adjustments and has consulted with endocrinology. Resident (R84) Provider reviewed residents blood sugars and chart, he does not wish to make any changes at this time. Resident (R116) Provider reviewed residents' chart and she increased notification parameters to from 380 to 400. Resident (R17) Provider reviewed blood sugars and due to residents' non-compliance, she will document to liberalize notification to physician to greater than 450. Provider is slightly adjusting sliding scale. Resident (R145)- Provider is comfortable with resident's current blood sugars, does not want to make any adjustments currently, has been reviewing closely. Resident (R148) Resident is out to the hospital due to a decline following an oncology treatment, unable to determine at this time if resident will return to the facility.

A facility wide audit will be conducted on all insulin dependent diabetic resident to ensure the proper sliding scale parameters are in the orders. This audit will also ensure all residents with out-of-range parameters have documented notifications to the resident representative if appliable, and the physician or other advanced practice provider.

An approved directed in-service provided by Masters Crafted in Healthcare will be a mandatory education requirement for all current licensed nurses and posted to agency platforms. The directed in-service is titled "Blood Glucose Monitoring, Assessment, Intervention, Notification and Documentation and will be presented to Whitehall Borough Post Acute on Thursday May 28th at 1800." Agency workers will not be permitted to work unless education has been completed.

The facility will conduct an audit of five randomly selected insulin-dependent diabetic residents per day for two weeks to ensure no blood sugar parameters have been documented outside of the prescribed range. If a parameter is identified as out of range, the audit will verify that appropriate intervention, provider notification, and repeat blood sugar documentation were completed. Following the initial two weeks, audits will be conducted four times per week for an additional two weeks. The findings will then be presented to QAPI to determine whether continued auditing is necessary.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on review of facility policy, observation and resident and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for two of four nursing units as required (TCU 1st.floor, and ARU1).

Findings included:

Review of the facility policy "Homelike Environment", dated 1/6/26, indicated "the staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting." These characteristics include a clean, sanitary, and orderly environment.

Observations on 5/4/26 at 10:38 a.m. and 5/725, at 8:30 a.m., revealed the following:
Resident rooms122, 125, 129, 133, 137, and 141 had wallpaper peeling off the walls.Resident room126 had a large stain on the ceiling. Resident room145 had a hole in the wall.
During an interview on 5/7/26 at approximately 9:15 a.m., the Nursing home Administrator confirmed the conditions of the residents' rooms.

Observations on 5/7/26 at 8:45 a.m. revealed the following:
Resident rooms404B and 405B had deep scratches in the walls near the window and the bathroom wall with black scratches and chipped drywall.
During an interview at approximately 8:30 a.m., the Director of Nursing confirmed the conditions of the residents' rooms.

During an interview on 5/7/26, at 9:40 a.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment.

28 Pa. Code: 201.29(k) Resident rights.
28 Pa. Code: 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 06/23/2026

The wallpaper in rooms 122, 125, 129, 133, 137, and 141 will be repaired. The large ceiling stain in room 126 will also be addressed. The deep scratches in the walls near the window and the bathroom wall with black scratches and chipped drywall will be repaired in room 404B and 405B. Lastly, the hole in the wall in room 145 will be patched.

An audit of the entire facility will be conducted to ensure there are no other areas with peeling wallpaper, ceiling stains, or holes in the walls. If any additional issues are identified, maintenance will address them as soon as possible.

The administrator and/or designee will educate the maintenance director on providing a safe/clean/comfortable homelike environment for the residents. Nursing and housekeeping will be educated on reporting areas in resident rooms that need repaired and the process for doing so to the maintenance department.

The facility will audit 5 random rooms 3 times a week x 4 weeks to ensure the residents room provide a homelike environment. The results will be taken to QAPI to determine if continuation is necessary.

§483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Plan of Correction - To be completed: 06/23/2026

Resident's R16, R62, R97, and R174 all had their ace wraps discontinued. Residents R32, R123, R130 and R147 all still have medically necessary reasons to continue ace wrap orders, the facility is auditing the ace wrap usage and ensuring they are being applied properly.

A facility-wide audit will be completed to review all residents with ordered ACE wraps and determine whether the continued use of the ACE wrap is still necessary. Additionally, the facility will audit all ACE wraps to ensure they are being applied properly and, on the resident, when scheduled.

The director of nursing and/or designee will educate all licensed nurses on how to properly apply an ace wrap and the importance of applying ace wraps when ordered. The education will include a visual demonstration with return observation to ensure proper education.

The facility will audit 5 random residents 4 times a week x 4 weeks to ensure ace wraps are applied when ordered and applied correctly. The findings will then be presented to QAPI to determine whether continued auditing is necessary.

483.70 REQUIREMENT Administration:

§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Observations:

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents (R3, R17, R64, R84, R116, R145, and R148).

Findings include:

Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, "The primary purpose of your job position is served as a licensed skilled nursing facility administrator, directing the day-to-day functions of an independent skilled nursing facility in accordance with federal, state, and local requirements that govern skilled nursing facilities, thus seeking to assure that the facility provides a high degree of quality of care to its residents."

Review of the facility-provided Director of Nursing (DON) job description indicated the essential duties of the DON include the overall management of the entire nursing department and staffing levels, develop and implement nursing polices and procedures and ensure compliance, responsible for ensuring resident safety.

Based on findings identified in this report, the facility failed to ensure that physicians or other advanced practice providers were notified of capillary blood glucose levels beyond the parameters set in the physicians' orders. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.

During an interview on 5/7/26, at approximately 3:00 p.m. the NHA and current DON confirmed that facility administration failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 06/23/2026

The regional director of clinical services will audit the job duties of the NHA and DON and report to the next schedule QAPI any concerns. The findings will then be presented to QAPI to determine whether continued auditing is necessary.

The NHA, DON, and/or ADON will perform 5 random observations of RBG monitoring a week for 4 weeks to ensure the proper protocol is being followed and correct documentation is being done.

An all staff meeting will be conducted by the NHA, DON, and ADON on the proper hyper and hypoglycemic protocol established by the facility once in the 4 week corrective action date.

5 random nurses for 4 weeks will be asked to reiterate the hyper and hypoglycemic protocols if an RBG is shown to be out of range to ensure the protocol is understood.

5 random residents charts 4 weeks with insulin orders will be checked each day to ensure proper protocols are being followed

Any nurse who fail to pass any of these checks will be reeducated on the proper protocols and have to pass a post test in order to work on the floor again.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of eight residents (Residents R13, R48 and R75).

Findings include:

Review of the facility policy, "Physician/Practitioner Orders Policy" dated 1/6/26, indicated to provide a general process for receiving, reviewing, implementing, clarifying, and documenting physician/practitioner orders while the resident is under the care of the facility. The facility will obtain and implement physician/practitioner orders in a manner to support resident care needs.

Review of the facility policy, "Wound Management Policy" dated 1/6/26, indicated care may be provided by practitioner orders and wound nurse recommendations. Documentation should reflect the care provided and may be completed in the treatment record.

Review of the clinical record indicated Resident R13 was admitted to the facility on 10/31/21.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 4/27/26, included diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), heart failure (the heart is unable to pump enough blood to meet the body's need for blood and oxygen), and hypertension (high blood pressure).

During rounds on 5/5/26, at approximately 9:30 a.m. Resident R13 was observed in bed with toenails that appeared to be thick, discolored, and fungus-like.

Review of a physician's orders for Resident R13 did not reveal an order for podiatry services.

During an interview on 5/5/26, at approximately 1:30 p.m. with the Director of Nursing (DON) confirmed there wasn't a podiatry order in the electronic health record (EHR) for the resident, and that the resident is currently followed by podiatry.

During an interview on 5/7/26, at approximately 7:45 a.m. the DON provided consultation reports from podiatry, for the dates of 1/6/26, 3/17/26, and 5/5/26 that were not observed in the residents EHR.

Review of the clinical record indicated Resident R75 was originally admitted to the facility on 2/25/26.

Review of the MDS dated 3/30/26, included diagnoses atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) pneumonia (lung infection) and hypertension (high blood pressure).

During rounds and an interview on 5/4/26, at approximately 10:30 a.m. with RN Employee E1 confirmed the resident was currently on oxygen at 2 liters. Resident R75 confirmed she uses oxygen most of the time.

Review of the care plan initiated 3/25/26, indicated that Resident R75 had shortness of breath or trouble breathing when lying flat. Included in the interventions was "Oxygen therapy as ordered."

Review of the vital signs' documentation reveals Resident R75 has utilized oxygen during 26 of the thirty days between 4/4/26 and 5/4/25.

Review of a physician's orders for Resident R75 did not reveal an order for the resident to be administered oxygen.

During an interview on 5/6/26, at approximately 9:00 a.m. the Director of Nursing (DON) confirmed there wasn't an order in the electronic health record (EHR) for the resident's oxygen administration.

Review of the clinical record indicated Resident R48 was admitted to the facility on 8/29/23.

Review of the MDS dated 2/7/26, included diagnoses of Parkinson's (a neurodegenerative disorder that affects movement) and diabetes.

Review of a skin note dated 3/18/26, indicated Resident R48 had a sacral (area of the buttocks) wound and a primary dressing of Therahoney (medical grade honey wound dressing designed to promote healing in wounds, and Border gauze (a specialized wound dressing) to be applied.

The clinical record did not include documentation of a physician order or documentation that the treatment was completed in the Treatment Record.

During an interview on 5/5/26 at 10:00 a.m., Wound Care Nurse Employee E2 confirmed the above findings that the wound dressing recommendations on 3/18/26, were not entered into the physician orders and not documented in the Treatment Administration Record, and that the facility failed to maintain records that were complete and accurate.

During an interview on 5/6/26, at approximately 10:00 a.m. the Nursing Home Administrator and the DON confirmed the facility failed to maintain clinical records that were complete and accurate.

28 Pa. Code: 211.5(f)(g)(h) Clinical records.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 06/23/2026

Resident R3 and R13 now have an order for podiatry services and has been seen by the podiatrist. Resident R75 now has updated orders to reflect the use of PRN oxygen. Resident R48 still received wound care, and his sacral wound has since healed.

The facility will conduct an audit on all residents who are seen by podiatry to ensure they have a corresponding order. All resident who receive oxygen therapy whether it is PRN or continuous will be audited to ensure proper order is in the medical records. And additionally, all wounds will be audited to ensure proper orders are present.

The director of nursing and/or designee will educate the nursing staff on ensuring all services provided to the resident, with special attention to podiatry, oxygen and wounds are entered into the patient record.

The facility will audit all new admissions and new wounds to ensure proper orders are placed into the medical record for 4 weeks.

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:

§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Plan of Correction - To be completed: 06/23/2026

The facility has been following up on the March QAPI.

The facility will audit any other adhoc QAPI's done in the past 90 days to ensure the facilities QAPI committee implemented a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services are audited correctly.

The regional director of nursing and/or designee will educate the members of the QAPI committee on ensuring QAPI plans are followed through entirely with audits, education and continuing conversation.

An audit will be conducted once a month during the QAPI to ensure all QAPI plans including adhoc QAPI's performed are followed through accurately.

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