Inspection Reports for
Wesley Enhanced Living Upper Moreland
2815 Byberry Rd, Hatboro, PA 19040, United States, PA, 19040
Back to Facility Profile21 Reports
Inspection Report — Mar 4, 2026
Renewal
Date: Mar 4, 2026
Visit Reason
The inspection was conducted as a renewal visit with an incident reason, including a full unannounced inspection on 03/04/2026.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were identified related to maintaining a current staff contact list and sanitary conditions in the ice cream freezer, both of which were corrected promptly.
Citations (2)
Regulation 62: The administrator did not maintain a current list of staff persons including substitute personnel and volunteers. This was corrected by adding missing staff and conducting audits to ensure accuracy.
Regulation 85a: Sanitary conditions were not maintained as a towel stained with food debris was found in the ice cream freezer. The towel was immediately removed and audits were implemented to prevent recurrence.
Report Facts
Residents Served: 26
Current Residents in Hospice: 3
Notice — Oct 31, 2025
Date: Oct 31, 2025
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation retention and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Mar 4, 2025
Date: Mar 4, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to education obtained outside the United States.
Findings
The waiver is granted with conditions including documentation of educational qualifications equivalent to a Bachelor of Science in Nursing and maintenance of such documentation in personnel files. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Feb 27, 2025
Date: Feb 27, 2025
Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee to serve as direct care staff based on education equivalency determined by a professional credential evaluator. The waiver is subject to conditions including documentation retention and annual review during inspections.
Notice — Feb 24, 2025
Date: Feb 24, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the educational qualification requirement for a direct care staff person has been granted.
Findings
The waiver is granted under the condition that the staff member's education obtained outside the United States is equivalent to a high school diploma, with documentation to be maintained and reviewed annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | RN, CCM, Bureau Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 23, 2025
Renewal
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including staff not knowing the location of the first aid kit, lack of thermometer in the ice cream freezer, incomplete emergency procedures, combustible materials stored near heat sources, use of prohibited portable space heaters, incomplete medication storage procedures, and missing signatures on support plans. All deficiencies had plans of correction submitted and were implemented by the date of the report.
Citations (7)
Staff person did not know the location of the first aid kit.
No thermometer in the ice cream freezer in the first-floor kitchen.
The home’s written emergency procedures do not include the contact information for each resident’s designated person.
Two cans of Oatey PVC Cement marked as flammable stored near boilers and hot water heaters.
Five portable space heaters were in use in the facility's main entrance.
Staff did not record all blood glucose readings in the medication record as required.
Resident and staff did not sign or date the support plan as required.
Report Facts
Residents Served: 31
Staffing Hours: 31
Waking Staff: 23
Number of Portable Space Heaters: 5
Number of Flammable Cans: 2
Inspection Date: Jan 23, 2025
Inspection Report — Feb 26, 2024
Renewal
Date: Feb 26, 2024
Visit Reason
The inspection was an unannounced renewal inspection conducted to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to staff training, resident accommodations, sanitary conditions, food storage, medication management, and documentation. The submitted plan of correction was determined to be fully implemented as of the review date.
Citations (16)
Direct care staff person A did not receive training in medication self-administration and meeting resident needs as described in screening and support plans during training year 2023.
Staff person B did not receive training in fire safety completed by a fire safety expert during training year January 2023 to December 2023.
Resident 1's bedside mobility device exceeded FDA guidelines for areas of entrapment and was not covered.
Resident 2's bedside mobility device exceeded FDA guidelines for areas of entrapment and was covered with a pillowcase which is not secure.
Resident 3 has a bedside mobility device attached to a board slid under the mattress and not securely attached to the bed frame.
Toilet in room 115 had feces smeared on it and soiled pants hanging on the grab bar next to the toilet.
Two uncovered, unattended trash cans in the first floor kitchenette.
Bins of chicken tenders and french fries in the first floor kitchenette freezer were opened and unsealed.
Unlabeled, undated chocolate cake, cheesecake, and an open bag of lettuce in the first floor kitchenette refrigerator.
Fire extinguisher in the first floor kitchenette was overcharged.
The home's menu for 02/26/24 was posted but the home did not have a two week menu posted.
Medication prescribed for resident 4 was discontinued but still present in the home's medication cart.
Glucometer for resident 4 was not calibrated for the correct date and time; blood sugar reading recorded incorrectly.
Medications were not administered to residents 4 and 5 as documented, with missed doses and refusal not properly noted.
Support plans for residents 1, 2, and 3 did not include specific need, intended use, risks, ability to use safely, device identification, or cover requirements for bedside mobility devices as per FDA guidelines.
Resident 1's and resident 2's records did not include a photograph no more than 2 years old.
Report Facts
Residents Served: 33
Total Daily Staff: 34
Waking Staff: 26
Inspection Report — Oct 19, 2022
Renewal
Date: Oct 19, 2022
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including a full unannounced visit on 10/19/2022 and 10/20/2022.
Findings
The facility was found to have multiple deficiencies including incomplete incident policies, delayed resident refund issuance after death, lack of refrigerator thermometers, outdated emergency management submission, inadequate medication procedures including missing medication investigations and documentation, incomplete resident assessments, and unsigned support plans. The submitted plan of correction was fully implemented by 12/06/2022.
Citations (11)
The home's written policy on reportable incidents does not address prevention, investigation, and management of reportable incidents and conditions.
Refunds for residents who passed away were not issued within the required 30 days.
No thermometer was present in the refrigerator in the drink station.
The home’s written emergency procedures have not been submitted to the local emergency management agency since 01/20/21.
The home's procedures do not include a process to investigate and account for missing medications and medication errors.
The home does not have a system to identify and document medication errors and patterns of errors.
There is no documentation of follow-up action taken to prevent future medication errors after two medication errors were documented.
Staff person administered medications outside their authorized scope of practice.
Resident assessment was not completed within 15 days of admission.
Resident assessments did not include accurate or complete information such as dietary needs and mobility status.
Residents participated in support plan development but did not sign the support plans.
Report Facts
Residents Served: 28
Medication errors documented: 2
Missing morphine amount: 8
Total Daily Staff: 30
Waking Staff: 23
Residents 60 Years or Older: 28
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Hospice Residents: 1
Inspection Report — Jul 21, 2021
Renewal
Date: Jul 21, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on July 21, 2021, to assess compliance with licensing requirements for Wesley Enhanced Living Upper Moreland.
Findings
The inspection identified several deficiencies including incomplete direct care staff training, overdue furnace inspection, failure to follow prescriber's orders for blood glucose monitoring, delayed resident assessments and support plans, and missing signatures on support plans. Plans of correction were accepted and implemented by the facility.
Citations (7)
Direct care staff person provided unsupervised ADL services without completing the Department-approved direct care training course and competency test.
The last furnace inspection was conducted on 4/29/2020, overdue for annual inspection.
Resident #1 did not have blood glucose readings documented as ordered; glucose meter battery needed replacement.
Resident #2 and #3 initial assessments were not completed within 15 days of admission.
Resident #2 and #3 initial support plans were not completed within 30 days of admission.
Resident #1's support plan did not document how medical, dental, vision, hearing, mental health or other behavioral care needs would be met.
Resident #2's support plan was not signed by the assessor.
Report Facts
Residents Served: 26
Total Daily Staff: 26
Waking Staff: 20
Notice — Feb 26, 2020
Date: Feb 26, 2020
Visit Reason
The document serves as a renewal notice and license issuance for the Personal Care Home following receipt of a renewal application.
Findings
The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement. Enforcement action may be taken if noncompliance is found during the inspection.
Inspection Report — Aug 28, 2019
Renewal
Date: Aug 28, 2019
Visit Reason
The inspection was a full, unannounced renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Violations of the Pennsylvania Personal Care Homes regulations were found, including failure to conduct required fire drills during sleeping hours and incomplete medical evaluations for residents. Plans of correction were submitted and approved to address these deficiencies.
Citations (2)
132e - Fire Drill Sleeping Hours: The last two overnight fire drills were conducted on 1/22/19 at 12:35 AM and 8/2/19 at 6:39 AM, failing to meet the requirement for a fire drill during sleeping hours every six months.
141a - Medical Evaluation Information: Resident #1's medical evaluation was incomplete, with missing medication addendum documentation and no attachment of the medical evaluation or resident medications in the record.
Report Facts
Resident Support Staff: 27
Total Daily Staff: 58
Waking Staff: 44
Residents Served: 27
Current Hospice Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sis Wichterman | Administrator | Named in relation to approval and signature of plans of correction |
Notice — Nov 13, 2018
Date: Nov 13, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Wesley Enhanced Living Upper Moreland Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for annual onsite inspections.
Findings
The document does not contain inspection findings but confirms the issuance of a regular license and the requirement for annual inspections to ensure compliance with applicable laws and regulations.
Inspection Report — Sep 10, 2018
Renewal
Date: Sep 10, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found violations related to food protection from contamination in the facility's kitchen refrigerator. A plan of correction was submitted addressing the uncovered food items and staff training on proper food handling.
Citations (1)
55 Pa.Code §2600.103(c) requires food to be protected from contamination while stored, prepared, transported, and served. Two plates of pie were uncovered in the first floor kitchen refrigerator, and one box of cheesecake was found open and unsealed.
Report Facts
Number of Residents Served: 27
Total Daily Staff: 33
Waking Staff: 25
Inspection Report — Mar 26, 2018
Complaint Investigation
Date: Mar 26, 2018
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to violations of 55 Pa. Code Chapter 2600 concerning Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific violations involved failure to report a resident death and medication errors. The complaint was substantiated as violations were found.
Findings
The facility was found to have multiple violations including failure to report a resident's death timely, medication administration errors involving incorrect narcotics, and failure to follow prescriber directions. Plans of correction were submitted addressing these issues.
Citations (3)
Regulation 2600.16(c) - The home failed to submit an incident report to the Department regarding a resident's death that occurred in the hospital.
Regulation 2600.186(b) - A Vicodin tablet prescribed for resident #2 was administered to resident #1.
Regulation 2600.187(d) - Resident #1 was not administered medication due to receiving the incorrect narcotic, and the physician was made aware.
Report Facts
Number of Residents Served: 31
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Florence Wichterman | Administrator | Named as legal entity representative and administrator in relation to findings and plan of correction. |
| Sabrina Freeman | Department representative conducting the inspection. |
Inspection Report — Nov 14, 2017
Renewal
Date: Nov 14, 2017
Visit Reason
The document is a renewal application and license issuance for Wesley Enhanced Living Upper Moreland Personal Care Home, indicating the Department will conduct an annual inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Inspection Report — Jan 25, 2017
Annual Inspection
Date: Jan 25, 2017
Visit Reason
The document reports the results of the Department of Human Services' annual licensing inspection of the facility conducted on January 25, 2017.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes during the annual licensing inspection.
Notice — Nov 14, 2016
Date: Nov 14, 2016
Visit Reason
The document serves as a renewal license certificate and letter for Wesley Enhanced Living Upper Moreland, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the renewal of the facility's license and outlines the Department's inspection requirements.
Report Facts
Inspection Report — Oct 3, 2016
Date: Oct 3, 2016
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident at Wesley Enhanced Living Upper Moreland.
Findings
The inspection found violations related to medication storage and control, specifically that narcotic medications were not stored in a locked area and some were missing. A plan of correction was submitted including termination of the responsible employee and staff policy reviews.
Citations (1)
Regulation 55 Pa.Code §2600.183(b) requires prescription medications, OTC medications, CAM and syringes to be kept in a locked area or container. Seven tablets of Oxycodone/APAP 5-325mg were not stored in a locked area and were discovered missing.
Report Facts
Number of Residents Served: 32
Staffing Hours - Total Daily Staff: 36
Staffing Hours - Waking Staff: 27
Missing narcotic tablets: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Kelly | Administrator | Signed plan of correction |
| Lauren Kazimer | Department representative on-site during inspection |
Notice — Jun 20, 2016
Date: Jun 20, 2016
Visit Reason
This letter responds to a request for a waiver of Pennsylvania Code Chapter 2600 requirements related to qualifications for direct care staff persons at Wesley Enhanced Living Upper Moreland.
Findings
The Department of Human Services granted the requested waiver, determining that the non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver approval letter. |
Inspection Report — Feb 2, 2016
Renewal
Date: Feb 2, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Wesley Enhanced Living Upper Moreland facility on February 2, 2016.
Findings
The facility was found to have a violation related to fire drill evacuation times exceeding the required 11 minutes. A plan of correction was implemented including in-service training and repeat fire drills to ensure compliance.
Citations (1)
55 Pa.Code §2600.132(d) requires residents to be evacuated within the time specified by a fire safety expert. The home's fire drill evacuation time was 14 minutes and 57 seconds, exceeding the 11-minute requirement.
Report Facts
Number of Residents Served: 32
Fire drill evacuation time: 897
Fire drill evacuation time: 510
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Kelly | Personal Care Administrator | Named as administrator and signer of plan of correction |
| Natasha Braswell | Department representative on-site during inspection | |
| Autumn Keppel | Department representative on-site during inspection |
Notice — January 29, 2021
Date: January 29, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, Wesley Enhanced Living Upper Moreland, and advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license following the renewal application.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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