Inspection Report
Renewal
Census: 23
Capacity: 50
Deficiencies: 3
Mar 31, 2025
Visit Reason
The inspection was conducted as a renewal visit to evaluate compliance with licensing requirements for Wesley Enhanced Living Pennypack Park.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies were identified related to staff training, menu posting, and medication storage procedures, all of which were corrected or had plans of correction accepted and implemented.
Deficiencies (3)
| Description |
|---|
| Direct care staff did not receive training on meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan, and on personal care service needs of the resident during training year 2024. |
| Menus posted on the dining-room wall were not dated, preventing residents from identifying the current week's menu. |
| The glucometer for a resident was calibrated one hour slow, causing incorrect logging of readings. |
Report Facts
License Capacity: 50
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Renewal
Census: 30
Capacity: 50
Deficiencies: 2
Jul 18, 2024
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented with no other violations noted during the audit. The facility demonstrated compliance with medication administration documentation and support plan medical/dental documentation requirements.
Deficiencies (2)
| Description |
|---|
| Resident #1’s July 2024 medication administration record did not include the initials of the staff person who administered Atorvastatin Calcium 10mg on 07/08/24 at 9pm. |
| Resident #1's assessment did not list psychological diagnoses indicated in the medical evaluation dated 03/14/24, including mild cognitive impairment and major depressive disorder. |
Report Facts
License Capacity: 50
Residents Served: 30
Total Daily Staff: 31
Waking Staff: 23
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 1
Inspection Report
Renewal
Census: 26
Capacity: 50
Deficiencies: 6
Jul 25, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The report found that the submitted plan of correction was fully implemented. Several deficiencies were identified related to quality management plan content, staff training, emergency procedure submissions, and medication storage procedures, all of which had corrective plans accepted and implemented by the facility.
Deficiencies (6)
| Description |
|---|
| The home's quality management reviews did not cover the periodic review and evaluation of complaint procedures, staff person trainings, and resident/family councils. |
| Direct care staff person A did not receive training during training year 2022 in medication self-administration and meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan. |
| Staff person A did not receive training during training year 2022 in emergency preparedness procedures and resident rights. |
| The home's record of its annual training review, dated December 2022, does not include the specific date of training, who provided the training, or the length of training. |
| The home’s written emergency procedures have not been submitted to a local emergency management agency since 11/21/2019. |
| Discrepancies between the log kept by the home of resident #1's glucometer readings and the glucometer's history display, including mismatched blood sugar readings on multiple dates. |
Report Facts
License Capacity: 50
Residents Served: 26
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 3
Inspection Report
Follow-Up
Census: 28
Capacity: 50
Deficiencies: 2
Mar 9, 2023
Visit Reason
The visit was a follow-up inspection 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. Specific deficiencies related to glucometer calibration and resident support plan documentation were addressed and corrected.
Deficiencies (2)
| Description |
|---|
| The glucometer for Resident #1 was not calibrated to the correct date and time. |
| Resident #1's support plan did not document the need for assistance with turning and positioning due to a rod in the resident's neck. |
Report Facts
License Capacity: 50
Residents Served: 28
Total Daily Staff: 30
Waking Staff: 23
Inspection Report
Monitoring
Census: 28
Capacity: 50
Deficiencies: 0
Aug 8, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/08/2022.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Total Daily Staff: 30
Waking Staff: 23
Resident Support Staff: 0
Residents Served: 28
License Capacity: 50
Current Hospice Residents: 2
Residents 60 Years or Older: 28
Residents with Mobility Need: 2
Inspection Report
Renewal
Census: 26
Capacity: 50
Deficiencies: 7
Aug 2, 2022
Visit Reason
The inspection was an unannounced renewal inspection of Wesley Enhanced Living Pennypack Park to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including outdated food labeling, incomplete medical evaluations, medication administration errors, improper storage procedures, delayed resident assessments and support plans, and unqualified direct care staff. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (7)
| Description |
|---|
| Outdated or unlabeled opened food items in dry storage area. |
| Resident medical evaluations missing answers for ability to self-administer medications and body positioning/movement. |
| Medication prescribed for a resident was not on the medication administration record. |
| Glucometer for a resident was not calibrated for correct date and time, causing inaccurate blood glucose logs. |
| Resident initial assessment was not completed within 15 days of admission. |
| Resident support plan was not completed within 30 days of admission. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
License Capacity: 50
Residents Served: 26
Current Hospice Residents: 2
Resident Mobility Need: 3
Residents with Physical Disability: 1
Staffing Hours - Resident Support Staff: 56
Staffing Hours - Total Daily Staff: 85
Staffing Hours - Waking Staff: 64
Inspection Report
Monitoring
Census: 30
Capacity: 50
Deficiencies: 2
May 13, 2022
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted: a strong urine odor related to sanitary conditions and a non-functioning flush toilet, both of which were corrected and verified as implemented.
Deficiencies (2)
| Description |
|---|
| Strong urine odor in resident's area indicating sanitary conditions were not maintained. |
| Resident's bedroom did not have a functioning flush toilet at the time of inspection. |
Report Facts
Residents Served: 30
License Capacity: 50
Total Daily Staff: 32
Waking Staff: 24
Inspection Report
Renewal
Census: 28
Capacity: 50
Deficiencies: 10
Sep 8, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 09/08/2021 to review compliance with licensing requirements.
Findings
The facility had multiple deficiencies including failure to post current license and inspection report, missing resident contract signatures, lack of signed statements acknowledging receipt of resident rights, unverified staff qualifications, inadequate bathroom ventilation, missing bedroom chairs, improper freezer temperatures, outdated emergency procedure submissions, and failure to post emergency procedures. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (10)
| Description |
|---|
| The home did not have their current license or previous inspection report posted in a conspicuous and public place. |
| Resident #1 and Resident #2 did not sign the resident-home contract nor was there documentation of inability or refusal to sign. |
| Resident #1 and Resident #2's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| The home did not provide documentation or verify that direct care staff person A's non US Secondary School education met the educational requirement. |
| The bathroom in bedroom #M217 does not have a window or ventilation fan. |
| Resident #1 does not have a chair in their bedroom. |
| Freezer (A) temperature exceeded 0°F on multiple dates including 9/8/21 when it was 9°F. |
| The home’s written emergency procedures have not been submitted to the emergency management agency since 2019. |
| The home’s emergency procedures are not posted in a conspicuous and public place in the home. |
| The home did not document that Resident #1 and Resident #2 were educated on the right to refuse medication if they believed there may be a medication error. |
Report Facts
License Capacity: 50
Residents Served: 28
Total Daily Staff: 31
Waking Staff: 23
Freezer Temperature Exceedances: 7
Inspection Report
Renewal
Census: 28
Capacity: 50
Deficiencies: 10
Sep 8, 2021
Visit Reason
The inspection was a renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/08/2021 to assess compliance with licensing requirements at Wesley Enhanced Living Pennypack Park.
Findings
The inspection identified multiple deficiencies including failure to post current license and inspection report, missing resident contract signatures, lack of signed statements acknowledging receipt of resident rights, unverified qualifications of direct care staff, inadequate bathroom ventilation, missing bedroom chairs for a resident, improper freezer temperatures, outdated emergency procedure submissions, and failure to post emergency procedures. Plans of correction were accepted for all deficiencies.
Deficiencies (10)
| Description |
|---|
| The home did not have their current license or previous inspection report posted in a conspicuous and public place. |
| Resident #1 and Resident #2 did not sign the resident-home contract nor was there documentation of inability or refusal to sign. |
| Resident #1 and Resident #2's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A's non US Secondary School education was not documented or verified to meet educational requirements. |
| The bathroom in bedroom #M217 does not have a window or ventilation fan. |
| Resident #1 did not have a chair in their bedroom. |
| Freezer (A) temperature exceeded 0°F on multiple dates including 9/8/21 when it was 9°F. |
| The home’s written emergency procedures had not been submitted to the emergency management agency since 2019. |
| The home’s emergency procedures were not posted in a conspicuous and public place in the home. |
| Resident #1 and Resident #2 were not documented as educated on their right to refuse medication if they believed there was a medication error. |
Report Facts
License Capacity: 50
Residents Served: 28
Total Daily Staff: 31
Waking Staff: 23
Freezer Temperature: 9
Freezer Temperature Exceedances: 7
Notice
Capacity: 50
Deficiencies: 0
Jun 2, 2021
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for Wesley Enhanced Living Pennypack Park, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection requirement.
Findings
The certificate confirms the facility is authorized to operate with a maximum capacity of 50 residents. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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