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Pennsylvania Nursing Homes Worst Offenders

Pennsylvania Nursing Homes Worst Offenders
What Are the Worst Nursing Homes in Pennsylvania? We Answer that Question and Say Why

Pennsylvania has approximately 700 nursing homes with a combined total of 88,000 beds. Obviously, not all nursing homes are created equally. Some are wonderful places with cheerful staff and few complaints. And others shock the conscience.

When we or a loved one moves into a nursing home, we have choices. As I write this, Pennsylvania’s nursing homes are about 90 percent occupied meaning there are plenty of good facilities that still have open beds. In this post we discuss the worst skilled nursing facilities in the Keystone State.

The state does not rate nursing homes from first to worst so what you are about to read is our opinion. But don’t just take our word for it, we share detailed reasons for our opinions.

Most of the facilities on this list has been designated as a “special focus facility.” That means the list consists of nursing homes that have a history of serious quality issues or are included in a special program to stimulate improvements in their quality of care.

Before we begin, we remind readers that Medicare puts rating information about all nursing homes online on their Nursing Home Compare website. Before a loved one moves into a skilled nursing facility, see how that facility measures up in terms of quality measures, staffing and safety. We also suggest you visit the nonprofit ProPublica’s Nursing Home Inspect page. Both sites are free and easy to navigate.

Here are our five picks for Worst Nursing Homes in Pennsylvania. This list reflects our opinion as of the day of writing. New inspections occur daily throughout the United States and sometimes new management or owners can transform a facility overnight. Nothing on this list is a substitute for checking the most recent inspection reports and kicking the tires by visiting the facility in question.

As to when you should visit, facilities are always at their best Monday through Friday during normal business hours. If possible, visit at night on a weekend or a holiday when staffing problems may be more apparent.

Gardens at West Shore

Starting at the very bottom our worst nursing home in Pennsylvania is Gardens at West Shore. This 309 bed for profit facility is located in Camp Hill, Pennsylvania.

Medicare uses a star rating system for nursing homes with one star being “much below average” and five stars being “much above average”. Gardens at West Shore is so bad that Medicare simply says that facility has such a “history of persistent poor quality” that it is designated as a “special focus facility.” If you were a kid in school, instead of getting an “F” on your report, this is the note from the principal saying you are so bad that you can’t go on to the next grade with the rest of the class.

According to Medicare, the average nursing home has 8 health citations. Gardens at West Shore has 48.

In the inspection report from April 2019, regulators say the facility generated 2 abuse and neglect deficiencies, 12 quality of life deficiencies, 13 for residents’ rights and 2 for nutrition.

Many of the deficiencies center around a lack of staffing. Without proper staffing, patients fall, wounds such as bedsores aren’t treated, bed linens are not changed and call bells are unanswered. In our opinion, Gardens at West Shore is not properly staffed. The January 2019 inspection found just that.

While there are facilities that had worse incidents occur, poor staffing is a big deal to us. An isolated incident can happen at any facility. Poor staffing is a recipe for continued mistakes and incidents. Gardens at West Shore is our worst nursing home based on poor staffing and an ongoing history of repeated violations and deficiencies.

The facility received an immediate jeopardy finding in 2017 for failing to protect residents from abuse. According to the report,

“Based on observation, interview and record review of resident records, the facility failed to investigate injuries of unknown origin to determine if abuse occurred and identify a perpetrator for two of nine residents (Resident 1 and 5) who received injuries of unknown origin and whose injuries resulted in altered mental status requiring hospitalization. This failure resulted in Immediate Jeopardy to all 186 residents of the facility.”

The online reviews are slightly below average. (We understand that online reviews are easily manipulated.) One recent negative review said,

“I highly urge you to go elsewhere. The management does not follow through on what they say they are going to do. The floors are highly understaffed, and the aids they do have (save for a few good ones who actually care about their patients and want to do their job correctly) are under-trained and downright lazy… I will say the nurses (and the Therapy Department) do a wonderful job, but there are only one or two per floor and they just can’t adequately provide care for the number of residents.”

That review is consistent with our view that poor staffing leads to a host of problems.

The Grove at North Huntington 

Close on the heals of Gardens at West Shore for worst nursing home in Pennsylvania is the Grove at North Huntington. Located in the town with the same name, this for profit facility has 120 beds.

Although our choice for the worst nursing home had 141 deficiencies according to Medicare, this facility had a staggering 175 and is also rated as a Special Focus Facility with a history of “persistent poor care.” It was also cited for abuse, a giant red flag in our book.

On paper, many of its demographics suggest it should be in “worst” place. The Gardens at West Shore (above), however, has that title because of its long history of problems and even after a change of ownership.

Another reason to give the Grove at North Huntington some credit is the encouraging Pennsylvania Department of Health report on November 20, 2019 finding that the facility had corrected the deficiencies listed in its previous inspection. A few more great report cards and we can remove this one from our list.

Despite the very recent state inspection, we remain very concerned about the quality of care at this facility. Observations included several unexplained patient injuries and a cognitively impaired patient who lost over 40 lbs. in several months without the patient’s physician being notified. That someone unable to fully communicate his or her needs could starve without a doctor being notified is alarming.

The most recent Medicare inspection report also found a medication error rate of 6.45 percent. Considering medication errors are a leading cause of death, that error rate unacceptable.

Twin Lakes Rehabilitation and Healthcare Center

The number three spot on our worst nursing homes in Pennsylvania list finds Twin lakes Rehabilitation and Healthcare. Located in Greenburg, this 137 bed facility is also operated by a for profit company. It too is not rated because it is a Special Focus Facility meaning it doesn’t even rate one star.

In its most recent report, inspectors noted that the facility failed to notify patients’ doctors of a change in a patient’s condition. One patient was found unresponsive yet no indication the doctor was notified despite a specific care plan instruction directing that the physician be notified of any change in condition.

Another resident claims he was in terrible pain. “This pain in my toe is worse than that, it's horrible. It's keeping me up at night, and I've asked to have the doctor look at it, but I don't think he was ever told.” The director of nursing confirmed the doctor should have been notified.

These are just a couple of the many deficiencies found at the facility. It is disappointing that every year auditors keep finding more problems.

While understanding that online reviews are easily manipulated, most of the reviews are bad.

Cathedral Village

Located in Philadelphia, Cathedral Village is a 133 bed non-profit facility affiliated with the Presbyterian faith. It is connected to an assisted living facility for those not in need of skilled nursing services.

Although touted as a luxury facility, its overall rating by Medicare is below average. Its health inspection rating is “much below average”.

A 2018 investigation made an immediate jeopardy finding against Cathedral Village. Those findings are rare and serious. According to a detailed investigation report, “the facility neglected to monitor and assess a resident for a change in condition, when the resident became unresponsive following a fall and subsequently died... This failure placed the residents at high risk of harm from neglect and placed the facility in an Immediate Jeopardy Situation.”

The investigation revealed that a patient had sustained several serious falls. [See our special report on nursing home falls and learn why most are preventable.] After one fall, the patient was found unconscious. Following instructions of the patient’s doctor and head trauma protocols, the patient was required to be observed and monitored over the next 72 hours.

The patient’s chart showed hourly neurological assessments including one for 7:20 am. That wasn’t possible since another employee had found the patient dead at 7:15 am. Subsequent review of security camera footage showed that none of the hourly checks were done for a seven hour period despite the chart showing they had been done.

That same security footage also showed that no one had changed the patient’s soiled sheets or reconnected his feeding tube. Even after being found unresponsive, no one attempted CPR.

We have always warned in our blog that one bad incident doesn’t land a facility on our worst nursing home list. The case of Cathedral Village is a bit different, however. The investigation revealed failures by multiple employees. This wasn’t the result of one rogue employee who falsified chart notes and failed to perform hourly checks because he or she was too busy or too lazy. The failures here were systemic in that they involved multiple employees.

A year later in 2019 an inspection found two residents were being verbally abused by healthcare staff. One of the two patient was cognitively impaired.

Nursing home residents are often quite vulnerable. They are frequently dependent on their caregivers for all their needs. There is simply no excuse for abuse.

[To the administrator of Cathedral Village, if you are reading this nothing would make us happier than to see a couple good inspection reports. Keep it together for at least a year and we will gladly remove you from our list. The same goes for all facilities on our Pennsylvania worst nursing home list.]

Willow Terrace

Willow Terrace in Philadelphia is last on the list. Although it had fewer overall deficiencies than our number one worst nursing home in Pennsylvania, it paid more in fines.

Willow Terrace is a for profit 174 bed facility. In its most recent Medicare rating it was rated overall as “much below average”, the worst rating possible. It’s staffing rating was below average. (If there is any bright spot, Willow Terrace received a good quality measures rating.) The feds say it 32 complaints in that last 3 years that resulted in citations.

A 2018 inspection resulted in an immediate jeopardy finding against the facility. According to the report,

“Based on observation, review of clinical records, facility policies and procedures, and facility documentation, and interviews with staff, it was determined that the facility failed to obtain and follow physician's orders related to the care and maintenance of intravenous (IV) catheters for two residents reviewed; failed to assess, monitor, identify and promptly intervene in response to an acute change in one resident's condition; and failed to assess and monitor 10 of 12 residents receiving blood thinning medication, causing actual harm to four residents who required hospitalization or prompted a delay in treatment related to abnormally elevated blood clotting levels. This failure placed residents receiving blood thinning medication at a high risk for injury and resulted in an Immediate Jeopardy situation.”

Once again, a single mistake won’t land you on our list. Here there were multiple patients placed in jeopardy including actual harm to four residents.

Pennsylvania Nursing Home Abuse Lawyers

No one in a nursing facility should ever have to suffer medication errors, neglect, verbal abuse sexual assault, bed sores or catastrophic falls. Yet these events happen daily (and far more than are reported). The nursing home abuse lawyers at Mahany Law and our national network can help patients and their families anywhere in United States.  Whether you or a loved one was abused or neglected in a Pennsylvania nursing home, adult day care, assisted living facility or a group home, we can help.

How Long Do I Have to Sue a Nursing Home in Pennsylvania?

Pennsylvania law generally gives personal injury and medical malpractice victims 2 years to sue. Lawsuits against nursing homes owned by the government have special rules, however.

Even though nursing home neglect victims typically have 2 years to sue, we recommend that if you or a loved one are injured in a nursing home you contact us immediately.

Why? It’s a sad reality that many folks in nursing homes are nearing the end of life. Memories fade, witnesses die, security camera footage is erased and staff turnover is often high. An experienced nursing home abuse lawyer can immediately begin to investigate and nail down important evidence and witnesses.

Damages in Pennsylvania Nursing Home Abuse Cases

Bringing a claim for personal injuries or other abuse does two things. It helps put a stop to bad behavior and can result in an award of significant monetary damages. Compensation is available for:

  • Medical Expenses (current and future)
  • Pain and Suffering
  • Emotional Distress and Mental Anguish
  • Disability
  • Disfigurement
  • Loss of Enjoyment of Life
  • Loss of Companionship

Pennsylvania is one of many states that does not cap or limit economic or non-economic damages such as pain and suffering. The state also allows punitive damages in particularly egregious cases however those may be limited to two times actual damages.

One of our nursing home abuse lawyers can help you determine what your case is worth.

For more information, visit our nursing home abuse page or for state specific information, our Pennsylvania elder abuse and neglect page. Ready to see if you have a case? Contact us online, by email [hidden email] or by phone 833.201.1555. All inquiries are protected by the attorney – client privilege. Cases handled nationwide.

[Our nursing home abuse cases are limited to serious bodily injury, sexual assault, death and bedsore cases. If we can’t help someone in our network probably can. Please note that we have lawyers licensed in many states. In those states where we do not have an office or licensed attorney, we typically co-counsel cases with local counsel.]


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