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🔎 Whitehall Borough Skilled Nursing And Rehab Center

Inspection Results


Inspection Overview

Whitehall Borough Skilled Nursing And Rehab Center has been cited for a total of 43 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2025-05-16
Correction Date: 2025-06-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Survey Date: 2025-05-16
Correction Date: 2025-06-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2025-05-16
Correction Date: 2025-06-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-05-16
Correction Date: 2025-06-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2025-05-16
Correction Date: 2025-06-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-02-20
Correction Date: 2025-04-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-12-12
Correction Date: 2025-01-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2024-12-12
Correction Date: 2025-01-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-12-12
Correction Date: 2025-01-08
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-09-09
Correction Date: 2024-10-08
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: F

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.

Survey Date: 2024-09-09
Correction Date: 2024-10-08
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Survey Date: 2024-06-13
Correction Date: 2024-07-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2024-06-13
Correction Date: 2024-07-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: B

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: B

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-05-09
Correction Date: 2024-06-18
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2024-04-08
Correction Date: 2024-05-16
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-12-19
Correction Date: 2024-02-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2023-12-19
Correction Date: 2024-02-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2023-10-05
Correction Date: 2023-11-10
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2023-05-05
Correction Date: 2023-06-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-05-05
Correction Date: 2023-06-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2023-05-05
Correction Date: 2023-06-12
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-05-05
Correction Date: 2023-06-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2023-05-05
Correction Date: 2023-06-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-17
Correction Date: 2022-07-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2022-06-17
Correction Date: 2022-07-22
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-11-29
Correction Date: 2022-01-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-02-05
Correction Date: 2021-03-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2021-02-05
Correction Date: 2021-03-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-02-05
Correction Date: 2021-03-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2020-12-11
Correction Date: 2021-01-07
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2019-05-10
Correction Date: 2019-05-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-05-10
Correction Date: 2019-06-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2019-05-10
Correction Date: 2019-05-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2019-05-10
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-05-10
Correction Date: 2019-06-26
Category: Pharmacy Service Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**