West Park Rehab: TB Precaution Failures Exposed - PA
That observation, recorded at West Park Rehabilitation and Nursing Center on the morning of March 30, 2026, was one of two infection control failures documented during a complaint inspection at the facility. In both cases, staff skipped required protective gear while providing direct care to high-risk residents. In both cases, a unit manager was present and confirmed the lapse after the fact.
Resident R3 had tested positive for tuberculosis on March 23, 2026. That same day, a physician's order went into the chart: airborne precautions, requiring a gown, face mask, face shield, and gloves for anyone entering the room. Tuberculosis spreads through the air. The particles are small enough to travel across a room and linger.
Seven days later, at 10:40 a.m., a licensed nurse identified in the inspection report as Employee E5 was observed in direct contact with Resident R3 wearing only a mask. No gown. No face shield. The unit manager, Employee E3, was there. She confirmed the nurse was out of compliance with the airborne precaution order.
Twenty minutes earlier, inspectors had documented a second failure in a different room.
Resident R2 is in a persistent vegetative state following anoxic brain damage. The resident has chronic obstructive pulmonary disease, a feeding tube placed through the abdomen, and a swallowing disorder that followed a brain injury. A physician's order from January 17, 2026, required enhanced barrier precautions for care involving the feeding tube. That order had been in place for more than two months when inspectors arrived.
At 10:20 a.m. on March 30, a nursing aide identified as Employee E4 was providing direct morning care to Resident R2 without a gown. The same unit manager, Employee E3, confirmed that observation too.
The facility's own written policy on enhanced barrier precautions states that staff must wear a gown and gloves when providing care involving significant physical contact to any resident with an indwelling medical device, including a feeding tube, regardless of the resident's infection status. The policy does not describe the requirement as discretionary. It does not carve out exceptions for morning care routines.
The Assistant Director of Nursing, Employee E7, told inspectors during a 9:00 a.m. interview that the facility was aware Resident R3 had been placed on airborne precautions following the tuberculosis diagnosis. That conversation happened before both observations were recorded. The precaution requirements were not a matter of dispute or confusion. They were documented, ordered, and acknowledged by nursing leadership before inspectors ever set foot in either room.
What the inspection captured was not a policy gap or a training deficiency that had gone unnoticed. It was the gap between what a facility puts on paper and what staff actually do when they walk through a door.
The inspection cited violations of Pennsylvania nursing home regulations governing resident care policies and nursing services. The harm level was assessed as minimal harm or potential for actual harm, the lower end of the federal deficiency scale. That classification reflects what inspectors could document, not what prolonged exposure to an undertreated tuberculosis environment might eventually produce for other residents, other staff, or the nursing aide who spent a morning providing hands-on care to a feeding tube patient without the gear her employer required her to wear.
Tuberculosis is not a historical curiosity. It remains one of the few airborne infections for which nursing homes must maintain specific isolation protocols, precisely because the populations inside these buildings, elderly, immunocompromised, living in close quarters, are among the most vulnerable to exposure. An N95 mask alone does not complete the precaution. The gown and face shield exist because the protocol was designed as a system, not a menu.
Resident R2 cannot speak. The inspection report describes a person with brain damage, in a vegetative state, dependent on a surgically placed tube for nutrition, unable to advocate for the protections a physician ordered on their behalf in January.
The aide providing that resident's morning care was not wearing the required gown. The supervisor confirmed it. The inspection report moved on to the next page.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Park Rehabilitation and Nursing Center from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for West Park Rehabilitation and Nursing Center
- Browse all PA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
WEST PARK REHABILITATION AND NURSING CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on March 30, 2026.
In both cases, staff skipped required protective gear while providing direct care to high-risk residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.