Inspection Report
Plan of Correction
Census: 53
Capacity: 79
Deficiencies: 1
Apr 7, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted on 04/07/2025 related to a fine and review of the submitted plan of correction.
Findings
The submitted plan of correction was fully implemented as of the inspection date. A medication labeling discrepancy was identified and corrected, with new policies and staff training implemented to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Resident's medication labeling did not include the prescribed dosage and instructions for administration as required. |
Report Facts
License Capacity: 79
Residents Served: 53
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 18
Residents Age 60 or Older: 52
Residents with Mobility Need: 19
Total Daily Staff: 72
Waking Staff: 54
Inspection Report
Follow-Up
Census: 48
Capacity: 79
Deficiencies: 4
Oct 31, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted on October 31, 2024, to review the implementation of the plan of correction submitted for violations cited in the October 31, 2024 inspection.
Findings
The inspection found that the submitted plan of correction for the October 31, 2024 inspection was not implemented. Deficiencies included failure to update support plans reflecting residents' behavioral changes, inadequate supervision leading to resident altercation and injury, incomplete medication administration documentation, and insufficient staff training hours in dementia care.
Deficiencies (4)
| Description |
|---|
| Resident #1's support plan was not updated to reflect behavioral changes and monitoring needs, leading to inadequate supervision and an altercation causing injury to Resident #2. |
| Medication administration records for Residents #1 and #2 lacked staff initials for certain medication doses and included a notation of medication given at a future date. |
| Support plans for Residents #1 and #2 were not revised to reflect changes in condition and needs after incidents. |
| Direct care staff in the Secure Dementia Care Unit had insufficient dementia care training hours during the January to December 2023 training year. |
Report Facts
License Capacity: 79
Residents Served: 48
Residents in Secured Dementia Care Unit: 18
Staffing Hours: 67
Waking Staff: 50
Training Hours: 4
Inspection Report
Complaint Investigation
Census: 53
Capacity: 79
Deficiencies: 16
Sep 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations following allegations or concerns at Wesley Enhanced Living at Stapeley.
Findings
Multiple violations were found including medication storage and labeling issues, training deficiencies, unsafe storage of poisonous materials, unsanitary conditions, and incomplete resident records. The facility was issued a provisional license with required plans of correction and follow-up inspections.
Complaint Details
The inspection was complaint-driven with findings substantiated by multiple violations including medication errors, training deficiencies, unsafe storage of poisonous materials, unsanitary conditions, and documentation issues. Follow-up inspections and plans of correction were required.
Deficiencies (16)
| Description |
|---|
| Direct care staff did not receive required training in safe management techniques and other annual training topics during 2023. |
| Staff training records lacked source and instructor information for multiple courses. |
| Poisonous materials were unlocked and accessible to residents in the memory care unit. |
| Unsanitary conditions found including possible blood stains, dirty shelves, dirty cutting boards, and strong odors. |
| Missing tiles on stairwell landings presenting slip and trip hazards. |
| Refrigerators leaking and lacking thermometers; food stored uncovered or unsealed. |
| Combustible materials stored improperly near heat sources. |
| Residents did not evacuate to designated fire-safe meeting places during drills. |
| Medications and syringes were found unlocked and unattended in resident rooms and medication carts. |
| Expired and undated medications found in medication carts. |
| Errors in documenting blood glucose levels for residents. |
| Directions for keypad locking devices not conspicuously posted near Secure Dementia Care Unit stairwell. |
| Resident record missing a photograph no more than 2 years old. |
| Resident-home contract not signed by administrator. |
| Direct care staff provided unsupervised ADL services without completing required training and competency test. |
| Menus lacked indication of current week in the 4-week cycle causing confusion. |
Report Facts
License Capacity: 79
Residents Served: 53
Residents in Secure Dementia Care Unit: 19
Staffing Hours - Total Daily Staff: 72
Staffing Hours - Waking Staff: 54
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 265
Mandated Correction Date: 5
Inspection Report
Complaint Investigation
Census: 53
Capacity: 79
Deficiencies: 14
Sep 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations following allegations or concerns raised about the facility.
Findings
Multiple violations were found including medication storage and labeling issues, training deficiencies, unsafe storage of poisonous materials, unsanitary conditions, fire safety concerns, and incomplete resident records. The facility was issued a provisional license with required plans of correction and follow-up inspections.
Complaint Details
The inspection was complaint-driven with findings substantiated by multiple violations related to medication management, staff training, safety hazards, sanitation, and documentation. Follow-up plans of correction were submitted with deadlines and enforcement actions pending.
Deficiencies (14)
| Description |
|---|
| Direct care staff did not receive required training in safe management techniques and other annual training topics during 2023. |
| Staff training records lacked complete information including source and instructor name. |
| Poisonous materials were unlocked and accessible to residents in the memory care unit. |
| Unsanitary conditions found including possible blood stains and dirty shelves in the memory care kitchen. |
| Floors and surfaces including stairwell tiles were damaged or missing, creating hazards. |
| Refrigerators were leaking and lacked thermometers; food was stored uncovered or unsealed. |
| Combustible materials stored improperly near heat sources. |
| Residents did not evacuate to designated fire-safe meeting places during drills. |
| Medications and syringes were found unlocked and unattended in resident rooms and medication carts. |
| Medications were stored improperly, including expired and undated medications. |
| Resident records lacked current photographs no more than 2 years old. |
| Resident-home contract was not signed by the administrator. |
| Direct care staff provided unsupervised ADL services without completing required training and competency testing. |
| Menus lacked indication of the current week in the menu cycle, causing confusion. |
Report Facts
License Capacity: 79
Residents Served: 53
Residents in Secured Dementia Care Unit: 19
Staffing Hours - Total Daily Staff: 72
Staffing Hours - Waking Staff: 54
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 265
Mandated Correction Date: 5
Inspection Report
Enforcement
Census: 53
Capacity: 79
Deficiencies: 15
Aug 1, 2024
Visit Reason
The inspection was conducted as a monitoring visit and complaint investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, including follow-up on previous violations and enforcement actions.
Findings
Multiple violations were found including deficiencies in staff training, medication storage and administration, sanitary conditions, safety hazards, record keeping, and contract compliance. The facility was issued a first provisional license due to these violations and is subject to fines and ongoing monitoring until full compliance is achieved.
Complaint Details
The complaint investigation was conducted on 09/26/2024 with findings including unlocked medications, expired eye drops, and issues with medication storage and labeling. Follow-up inspections and plan of correction submissions were scheduled.
Deficiencies (15)
| Description |
|---|
| Direct care staff did not receive required training in safe management techniques and other annual training topics. |
| Training records lacked source and instructor information for several courses. |
| Poisonous materials were unlocked and accessible to residents in the memory care unit. |
| Unsanitary conditions found including possible blood stains and dirty kitchen shelves. |
| Floors and stairwell surfaces were damaged and hazardous. |
| Refrigerators leaking and lacking thermometers; food stored uncovered or unsealed. |
| Combustible materials stored near heat sources. |
| Residents did not evacuate to designated fire-safe meeting places during drills. |
| Medications and syringes were not always locked or properly stored. |
| Errors in medication storage and labeling, including expired and undated medications. |
| Blood glucose levels were inaccurately documented in medication administration records. |
| Directions for keypad locking devices were not conspicuously posted. |
| Resident records lacked current photographs. |
| Resident-home contract was not signed by the administrator. |
| Menus lacked indication of the current week in the cycle, causing confusion. |
Report Facts
License Capacity: 79
Residents Served: 53
Residents Served in Secured Dementia Care Unit: 21
Residents Served in Secured Dementia Care Unit: 19
Fine Per Resident Per Day: 5
Calculated Fine: 265
Staffing Hours: 75
Waking Staff: 56
Staffing Hours: 72
Waking Staff: 54
Inspection Report
Renewal
Census: 61
Capacity: 79
Deficiencies: 22
May 20, 2024
Visit Reason
The inspection was a renewal visit conducted on May 20 and 21, 2024, to assess compliance with licensing requirements and verify correction of previous violations.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, staff qualification issues, incomplete staff training, unsafe resident equipment, unsecured poisonous materials, unsanitary conditions, fire safety violations, and medication storage errors. Plans of correction were directed or accepted with specified completion dates.
Deficiencies (22)
| Description |
|---|
| The most recent Licensing Inspection Summary dated 2/23/2023 was not posted in a conspicuous and public place on 5/20/2024. |
| Staff Person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff Person B did not complete training on the Emergency medical plan within 40 scheduled working hours. |
| Staff Persons C and D did not receive in-person fire safety training during 2023–2024. |
| Bed rails in Rooms 220 and 208 were not securely attached or missing. |
| Poisonous materials including toothpaste and cleaners were unlocked and accessible to residents not assessed as capable of safe use. |
| Strong odors of cat urine and unsanitary trash conditions were noted in multiple areas including memory care unit kitchen and bathrooms. |
| Trash cans in kitchens and bathrooms were uncovered and unattended. |
| Trash outside the home was improperly stored in green bags and wood pallets. |
| Broken stairs on fire tower and missing floor tiles on stairwell #4 created hazards. |
| Staff Person E did not know the location of the first aid kit. |
| Ramp leading to building had multiple cracks and broken concrete creating tripping hazards; 4th floor deck was mossy and slippery. |
| No thermometer was present in the memory care unit refrigerator. |
| Unlabeled and undated pitchers of drinks were found in the main kitchen refrigerator. |
| The home pets policy did not specify permitted pets; a no pet policy was implemented. |
| A silver car was blocking a fire exit egress route. |
| Fire extinguisher in facility bus was not UL listed or approved by Factory Mutual Systems. |
| Unannounced fire drills were not held from November 2022 to February 2023 and from December 2023 until inspection date. |
| Residents were unaware of the designated meeting place for fire drills. |
| Resident medical evaluations lacked pertinent emergency and medication information. |
| Medication storage errors included incorrect glucometer readings recorded and loose pills found on medication carts. |
| Resident initial assessments were not completed within 15 days of admission. |
Report Facts
License Capacity: 79
Residents Served: 61
Secured Dementia Care Unit Capacity: 30
Residents Served in Dementia Unit: 23
Total Daily Staff: 84
Waking Staff: 63
Repeated Violations: 2
Inspection Report
Complaint Investigation
Census: 62
Capacity: 79
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Wesley Enhanced Living at Stapeley on 05/15/2024.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 85
Waking Staff: 64
License Capacity: 79
Residents Served: 62
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 23
Residents Age 60 or Older: 61
Residents with Mobility Need: 23
Inspection Report
Monitoring
Census: 58
Capacity: 79
Deficiencies: 6
Feb 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on 02/23/2023 to review the facility's compliance and plan of correction implementation.
Findings
The facility was found to have multiple deficiencies related to staff training, medication storage, medication administration documentation, and following prescriber's orders. The submitted plan of correction was accepted and later determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Staff person did not complete required orientation training within 40 scheduled work hours including emergency medical plan and mandatory reporting of abuse and neglect. |
| Resident #1's medication did not include the date it was opened; medication must be discarded after 28 days. Resident #2's medication blister pack was found with tape holding a tablet. |
| Resident #1's glucose reading was not performed as documented; medication administration record had inaccurate documentation. |
| Resident #1's medication administration record did not include initials of staff administering medications on specified dates and times. |
| Resident #1's physician was not notified of abnormal blood glucose readings; some glucose readings were not completed. |
| Resident #1's medication was not administered due to unavailability in the home. |
Report Facts
License Capacity: 79
Residents Served: 58
Total Daily Staff: 83
Waking Staff: 62
Inspection Report
Renewal
Census: 59
Capacity: 79
Deficiencies: 12
Sep 28, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements and regulations.
Findings
The facility had multiple deficiencies including lack of carbon monoxide detector near the kitchen stove, missing criminal background checks for staff, incomplete fire safety orientation for new staff, lighting issues on emergency exit routes, evacuation drills exceeding designated time, medication storage and administration errors, incomplete resident assessments and support plans. All deficiencies had plans of correction submitted and were implemented by April 21, 2023.
Deficiencies (12)
| Description |
|---|
| No carbon monoxide detector within 15 feet of the kitchen gas stove. |
| Staff member hired without a criminal background check. |
| Staff person did not receive required fire safety orientation on first day of work. |
| Lighting not adequate on first-floor exit tower #1 during the day. |
| Evacuation drills exceeded the designated evacuation time of 11 minutes on multiple occasions. |
| Discontinued medication was present on medication cart. |
| Controlled substance sign out sheet missing date, time, or signature for medication removal. |
| Medication administration records missing initials of staff who administered medications. |
| Failure to follow prescriber's orders for blood glucose monitoring and documentation. |
| Staff person administered medications without completing Department-approved medication administration course. |
| Resident assessments not completed within 15 days of admission. |
| Resident's initial support plan for Secure Dementia Care Unit admission not completed within required timeframe. |
Report Facts
License Capacity: 79
Residents Served: 59
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 23
Evacuation Drill Time: 12
Total Daily Staff: 82
Waking Staff: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in deficiency for missing criminal background check. | |
| Staff person B | Named in deficiency for missing fire safety orientation on first day. | |
| Staff person C | Named in deficiency for administering medications without completing required medication administration course. |
Inspection Report
Follow-Up
Census: 54
Capacity: 79
Deficiencies: 11
Jun 24, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the full implementation of a previously submitted plan of correction, triggered by a renewal and complaint reason.
Findings
The facility was found to have implemented the plan of correction fully, with various deficiencies related to posting of rights poster, staff qualifications, first aid/CPR training, facility maintenance, hot water temperature, use of common towels, refrigerator/freezer temperatures, prohibited procedures, and documentation for secured dementia care unit admissions. All deficiencies were accepted with corrective actions and completion dates provided.
Complaint Details
The visit was partially complaint-related, as indicated by the inspection reason 'Renewal, Complaint'. Specific substantiation status is not stated.
Deficiencies (11)
| Description |
|---|
| The Department's resident's rights poster was not posted in a conspicuous and public place in the home. |
| The administrator did not have a required license or qualifications as a registered nurse or nursing home administrator. |
| Only one staff person certified in first aid, obstructed airway techniques and CPR was present from 11:00 PM to 7:00 AM for 52 residents. |
| Stairwell #4 had tiles torn up presenting a tripping hazard; ceiling tiles in closet of room 327 were dirty and warped from water damage. |
| Hot water temperature at bathroom sink in room 320 measured 129.0°F and 128.4°F, exceeding the 120°F limit. |
| Unlabeled wash cloths and towels were hanging in the shared bathroom of room 320, violating prohibition on common towels. |
| No thermometer was present in the line prep refrigerator in the kitchen. |
| Three chairs were placed at the entrance way of the dining room to prevent residents from entering, constituting a mechanical restraint. |
| Resident #1's medical evaluation documenting diagnosis of dementia and need for secured dementia care unit was not completed timely. |
| Resident #1's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident #1's initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
Residents served: 54
License capacity: 79
Residents served in secured dementia care unit: 23
Capacity of secured dementia care unit: 30
Current hospice residents: 1
Residents diagnosed with mental illness: 2
Residents with mobility need: 23
Residents age 60 or older: 54
Hot water temperature: 129
Hot water temperature: 128.4
Staff certified in first aid/CPR: 1
Residents present during CPR deficiency: 52
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