Inspection Reports for Wesley Enhanced Living Doylestown
200 VETERANS LANE,, PA, 18901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
71% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 53
Capacity: 75
Deficiencies: 0
Sep 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 09/30/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 75
Residents Served: 53
Total Daily Staff: 54
Waking Staff: 41
Residents 60 Years or Older: 53
Residents with Mobility Need: 1
Inspection Report
Renewal
Census: 49
Capacity: 75
Deficiencies: 5
Sep 16, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility Wesley Enhanced Living Doylestown on 09/16/2024 and 09/17/2024 to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including hazards on the exterior exit walkway, improper food storage, obstructed emergency egress signage, medication administration errors, and incomplete medication administration training records. All deficiencies had plans of correction accepted and were implemented by 12/04/2024.
Deficiencies (5)
| Description |
|---|
| First-floor exit had an extension cord on the ground of the exit walkway path, creating a tripping hazard. |
| Four tubs of ice cream were opened or unsealed in the freezer box. |
| A sign with a RED STOP SIGN reading 'PC residents are not to use the stairs unless there is an emergency' was present on stairwell exit doors, obstructing emergency egress. |
| Resident #1 was administered medication incorrectly, not following prescriber's orders, with repeated violations noted. |
| Medication administration training records for two staff persons did not include documentation of successful completion of the annual practicum training. |
Report Facts
License Capacity: 75
Residents Served: 49
Current Hospice Residents: 5
Resident with Mobility Need: 1
Resident with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 57
Capacity: 75
Deficiencies: 0
Feb 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 02/26/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 75
Residents Served: 57
Total Daily Staff: 59
Waking Staff: 44
Residents Age 60 or Older: 57
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 63
Capacity: 75
Deficiencies: 8
Jun 26, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Wesley Enhanced Living Doylestown on 06/26/2023 and 06/27/2023.
Findings
The inspection found multiple deficiencies including unsigned resident contracts, delayed refund issuance after resident deaths, missing signed statements acknowledging receipt of resident rights, lack of emergency telephone numbers in a resident room, medication administration errors, incomplete controlled substance sign-out sheets, failure to follow prescriber's orders, and lack of resident education on the right to refuse medication. Plans of correction were accepted and fully implemented by 11/09/2023.
Deficiencies (8)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Refund checks for residents #3 and #4 were not issued within the required timeframe after death and removal of personal belongings. |
| Resident #1 and #2's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| No emergency telephone numbers posted on or by the telephone in resident room #515. |
| Resident #5 was administered bedtime medications instead of the prescribed morning medication, failing to follow the 5 Rights of Medication Administration. |
| Controlled substance sign-out sheet for resident #6's Andro Gel ran out of space and no additional sheet was requested until late. |
| Resident #5's prescribed daily weights were not measured on 06/26/2023. |
| Residents #1 and #2 were not educated on their right to refuse medication if they believed there was a medication error. |
Report Facts
License Capacity: 75
Residents Served: 63
Total Daily Staff: 67
Waking Staff: 50
Hospice Residents: 1
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Pinzka | Administrator | Named as facility administrator in the report. |
Inspection Report
Follow-Up
Census: 58
Capacity: 75
Deficiencies: 1
Jan 12, 2023
Visit Reason
The visit was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The violation involved a delayed incident report regarding missing rings, which was corrected by new procedures and staff training.
Deficiencies (1)
| Description |
|---|
| The home did not report an incident involving missing 14k diamond rings to the Department within the required 24-hour timeframe. |
Report Facts
License Capacity: 75
Residents Served: 58
Total Daily Staff: 60
Waking Staff: 45
Current Hospice Residents: 1
Residents Age 60 or Older: 58
Residents with Mobility Need: 2
Residents with Physical Disability: 3
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Administrator | Named as responsible for root cause of delayed incident reporting and involved in corrective training | |
| Executive Director | Trained on new incident reporting policy as part of corrective action | |
| Personal Care LPNs | Trained on new incident reporting policy as part of corrective action | |
| Security Guards | Trained on new incident reporting policy as part of corrective action | |
| Director of Facility Operations | Trained on new incident reporting policy as part of corrective action | |
| Facilities Supervisor | Trained on new incident reporting policy as part of corrective action | |
| Resident Life Services Manager | Trained on new incident reporting policy as part of corrective action |
Inspection Report
Census: 59
Capacity: 75
Deficiencies: 0
Nov 18, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 75
Residents Served: 59
Total Daily Staff: 61
Waking Staff: 46
Residents 60 Years or Older: 62
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 2
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 64
Capacity: 75
Deficiencies: 0
Aug 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 08/22/2022.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or substantiated issues were found.
Report Facts
License Capacity: 75
Residents Served: 64
Total Daily Staff: 67
Waking Staff: 50
Current Hospice Residents: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 2
Residents 60 Years or Older: 64
Inspection Report
Renewal
Census: 69
Capacity: 75
Deficiencies: 1
Mar 28, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction related to medication administration discrepancies was fully implemented and compliance was maintained. The inspection identified minor discrepancies in glucometer readings recorded on the Medication Administration Record, but no medication errors resulted.
Deficiencies (1)
| Description |
|---|
| Discrepancies in resident 1's glucometer readings recorded on the Medication Administration Record (MAR) on multiple dates. |
Report Facts
License Capacity: 75
Residents Served: 69
Staffing Hours: 73
Waking Staff: 55
Hospice Residents: 1
Residents with Mobility Need: 4
Residents with Physical Disability: 3
Residents Diagnosed with Intellectual Disability: 1
Residents 60 Years or Older: 69
Inspection Report
Complaint Investigation
Census: 63
Capacity: 75
Deficiencies: 2
Nov 9, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation at Wesley Enhanced Living Doylestown.
Findings
The inspection found medication administration errors involving two residents, including incorrect insulin dosing due to misreading blood sugar levels and administration of incorrect eye drops. The facility submitted a plan of correction which was determined to be fully implemented.
Complaint Details
The visit was complaint-related, investigating medication errors involving insulin administration and incorrect medication given to residents. The submitted plan of correction was fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1 received 6 units of insulin instead of the prescribed 2 units due to staff misreading the blood sugar reading. |
| Resident #2 was administered Carbamide Peroxide ear drops in the eyes instead of prescribed Artificial Tears Solution. |
Report Facts
License Capacity: 75
Residents Served: 63
Staffing Hours - Resident Support Staff: 66
Staffing Hours - Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication error involving insulin administration |
Notice
Capacity: 75
Deficiencies: 0
Jun 22, 2021
Visit Reason
The document serves as a response to the renewal application submitted on March 30, 2021, for the operation of Wesley Enhanced Living Doylestown Personal Care Home and notifies that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license issuance and renewal notification letter.
Report Facts
Total licensed capacity: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal application response letter. |
Inspection Report
Follow-Up
Census: 49
Capacity: 75
Deficiencies: 1
May 13, 2021
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to support plan revisions for residents.
Findings
The facility was found to have fully implemented the plan of correction regarding updating residents' support plans to accurately reflect medication administration needs. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| Resident #1's support plan was not updated to reflect changes in medication administration needs, despite the resident being unable to self-administer some medications. |
Report Facts
Residents Served: 49
License Capacity: 75
Staffing Hours - Total Daily Staff: 50
Staffing Hours - Waking Staff: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter confirming plan of correction implementation | |
| Director of Personal Care | Responsible for ensuring updates to Resident RASPs | |
| Personal Care Administrator | Audited residents' RASPs to ensure updates | |
| Personal Care Nurse | Involved in following procedures for updating/auditing RASPs |
Inspection Report
Renewal
Census: 55
Capacity: 75
Deficiencies: 8
Feb 11, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility Wesley Enhanced Living Doylestown on 02/11/2021 and 02/12/2021 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection identified multiple deficiencies including failure to issue a timely refund after a resident's death, incomplete staff training plan, lack of current rabies vaccination certificates for pets, incomplete notice to the fire department, discrepancies in medication storage and documentation, failure to educate a resident on the right to refuse medication, incomplete preadmission screening documentation, and improper destruction of resident records. All deficiencies had accepted plans of correction and were reported as fully implemented.
Deficiencies (8)
| Description |
|---|
| Resident refund was not issued within 30 days after resident's death and room clearance. |
| Staff training plan did not include job titles/positions of staff persons. |
| Two felines present at the home did not have current certificates of rabies vaccination. |
| Notice to the fire department did not document location of bedrooms, home layout, or total capacity. |
| Discrepancies between glucometer readings and medication administration record entries for Resident #2. |
| Resident #3 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #2's preadmission screening form was completed after admission date. |
| The home destroyed 7 resident records for individuals discharged less than 3 years ago. |
Report Facts
License Capacity: 75
Residents Served: 55
Current Hospice Residents: 2
Total Daily Staff: 60
Waking Staff: 45
Number of Residents Age 60 or Older: 55
Number of Residents with Intellectual Disability: 1
Number of Residents with Physical Disability: 2
Number of Residents with Mobility Need: 5
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