Inspection Reports for Wesbury United Methodist Community
31 NORTH PARK AVENUE,, PA, 16335
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
49% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 54
Capacity: 110
Deficiencies: 5
Jan 15, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 01/15/2025 to review the facility's compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including delayed access to staff records, incomplete criminal background checks for some staff, insufficient first aid/CPR trained staff coverage, incomplete staff training plan content, and incomplete documentation in resident support plans. Plans of correction were submitted and accepted with completion dates ranging from February to December 2025.
Deficiencies (5)
| Description |
|---|
| Delayed access to staff records requested by Department agents on 1/15/25. |
| No criminal history background check was completed for staff person D; background checks for staff persons A, B, and C were delayed but eventually provided. |
| Insufficient first aid/CPR trained staff present during multiple shifts when 54 residents were in the home. |
| The 2025 Staff Training Plan did not include the name, position and duties of each direct care staff person or locations of scheduled training. |
| Resident support plans for two residents did not include necessary information about use of enabler bar, bedrail, and vision problems. |
Report Facts
Residents served: 54
License capacity: 110
Total daily staff: 57
Waking staff: 43
Residents with mobility need: 3
Residents aged 60 or older: 54
Inspection Report
Follow-Up
Census: 60
Capacity: 110
Deficiencies: 2
Apr 23, 2024
Visit Reason
The inspection visit on 04/23/2024 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to medication administration errors was found to be fully implemented. The facility demonstrated ongoing compliance with medication management procedures, including re-education of staff and scheduled audits.
Deficiencies (2)
| Description |
|---|
| Medication was administered to the wrong resident, violating the requirement that prescription medications be used only by the resident for whom prescribed. |
| Failure to follow prescriber's orders resulting in a resident not receiving prescribed medications as directed. |
Report Facts
License Capacity: 110
Residents Served: 60
Total Daily Staff: 65
Waking Staff: 49
Residents Age 60 or Older: 59
Residents with Mobility Need: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Nurse Manager | Responsible for root cause analysis, re-education of Med Tech staff, and conducting unannounced medication audits |
Inspection Report
Renewal
Census: 64
Capacity: 110
Deficiencies: 13
Dec 14, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to staff training, labeling of poisonous materials, trash receptacle coverage, hot water temperature, food storage, lint removal, rabies vaccination, fire drills, medical evaluations, medication labeling, and resident assessments. All deficiencies had plans of correction accepted and were implemented by the report date.
Deficiencies (13)
| Description |
|---|
| Staff person A did not receive 12 hours of annual training in training year 2022. |
| Staff person A did not receive training in required topics including medication self-administration, dementia care, infection control, personal care needs, and safe management techniques during training year 2022. |
| Staff person A did not receive training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during training year 2022. |
| Unlabeled spray bottles containing poisonous materials were found in the kitchen. |
| Uncovered trash cans in the kitchen and dishwash room. |
| Hot water temperature exceeded 120°F in multiple resident-accessible sinks. |
| Food stored on the floor in the main kitchen walk-in freezer. |
| Accumulation of lint in lint traps of industrial dryers. |
| Resident's cat did not have a current rabies vaccination certificate. |
| Fire drill during sleeping hours was not conducted as required. |
| Resident medical evaluations were not completed or documented as required. |
| OTC medications and CAM were not labeled with the resident's name. |
| Resident initial and additional assessments did not include all required diagnoses. |
Report Facts
Inspection Dates: 3
Staffing Hours: 69
Waking Staff: 52
Residents Served: 64
License Capacity: 110
Hot Water Temperature: 135.5
Trash Can Size: 55
Trash Can Size: 30
Lint Accumulation: 1
Inspection Report
Complaint Investigation
Census: 40
Capacity: 110
Deficiencies: 2
Apr 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse involving staff person A and resident #1.
Findings
The investigation found that staff person A forcibly administered medication to resident #1 without proper consent, causing fear in the resident. The abuse was not reported timely to the appropriate authorities. Corrective actions including staff education, suspension, and termination of the alleged perpetrator were implemented.
Complaint Details
The complaint involved an incident where staff person A forcibly administered medication to resident #1 without applesauce or water, causing the resident to refuse initially and later fear the staff member. The incident was reported late to the local Area Agency on Aging and the Department. The complaint was substantiated with corrective actions taken including staff suspension, termination, and education.
Severity Breakdown
SQ: 3
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately report suspected abuse of a resident as required by law. | SQ |
| Resident abuse involving forced medication administration and intimidation. | SQ |
Report Facts
Residents Served: 40
License Capacity: 110
Number of Pills: 5
Staff Total Daily: 41
Waking Staff: 31
Current Hospice Residents: 1
Residents Age 60 or Older: 40
Inspection Report
Renewal
Census: 56
Capacity: 110
Deficiencies: 9
Dec 13, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, including a full unannounced review from 12/13/2022 to 12/15/2022.
Findings
The inspection found multiple deficiencies including incomplete financial records for residents, unsigned contracts by payers, lack of staff orientation on fire safety and abuse reporting, unsecured resident equipment posing fall hazards, unsecured medications, discontinued medications present, incorrect medication records, and missing times on medication administration records. All deficiencies had plans of correction accepted and were implemented by January 2023.
Deficiencies (9)
| Description |
|---|
| Resident #1 and #2 financial records did not include the resident’s account balance. |
| Resident #3 and #2 resident/home contracts were not signed by the payer as required. |
| Staff person A had no record of receiving orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff person A had no record of receiving orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents within first 40 scheduled working hours. |
| Bed enabler attached to resident #4’s bed was unsecured, causing a potential fall hazard. |
| Unattended, unsecured, and accessible Preparation H ointment found in resident #5’s bathroom. |
| Discontinued medication Coricidin HBP found in resident #3’s medication cart. |
| Multiple incorrect blood glucose readings entered into resident #3’s medication administration record. |
| Resident #2, #3, #4, and #5 December 2022 Medication Administration Records did not indicate the time of administration for multiple medications. |
Report Facts
License Capacity: 110
Residents Served: 56
Total Daily Staff: 60
Waking Staff: 45
Hospice Residents: 2
Residents with Mobility Need: 4
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Deficiencies: 0
Nov 8, 2021
Visit Reason
The document summarizes the results of multiple licensing inspections conducted on 09/29/2021, 10/25/2021, 10/28/2021, 11/01/2021, and 11/08/2021 for the facility.
Findings
No regulatory citations were identified as a result of these inspections.
Report Facts
Inspection dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Duncan | Signed the letter summarizing inspection results |
Inspection Report
Renewal
Census: 63
Capacity: 110
Deficiencies: 7
Aug 25, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with an unannounced full inspection on 08/25/2021 and an exit conference on 08/26/2021.
Findings
The inspection identified several deficiencies including missing resident-home contract, unsecured enabler bar posing entrapment hazard, lint accumulation in dryer lint traps, overdue fire extinguisher inspection on the facility bus, improperly calibrated glucometer, missed blood glucose check, and incomplete medication administration training records. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (7)
| Description |
|---|
| Resident #1 did not have a resident-home contract completed. |
| Resident #2 has an enabler bar on bed not secured, posing an entrapment hazard. |
| Approximate 1/4 inch lint accumulation in lint trap of commercial dryer #3 and 1/2 inch in dryer #5. |
| Fire extinguisher in 2018 Ford Bus used to transport residents had not been inspected since March 2020. |
| Resident #3's glucometer was not calibrated to the correct date (8/25/21). |
| Resident #3 missed a prescribed blood glucose check on 8/24/21 at 4:00 p.m. |
| Medication administration training record for staff person A does not include the date of recertification. |
Report Facts
License Capacity: 110
Residents Served: 63
Staffing: 70
Waking Staff: 53
Current Hospice Residents: 1
Residents with Mobility Need: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication administration training record deficiency. | |
| RN Nurse Manager | RN Nurse Manager | Provided staff training and audited glucometers and medication technician records. |
| RN Nurse Supervisor | RN Nurse Supervisor | Maintains and reviews medication technician records and recertifications. |
Notice
Capacity: 110
Deficiencies: 0
Mar 25, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for Wesbury United Methodist Community, a Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 110
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