30 Reports
Inspection Report — Apr 9, 2026
Complaint Investigation
Date: Apr 9, 2026
Visit Reason
The inspection was conducted as a complaint investigation at the facility on April 9, 2026.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 66
Inspection Report — Aug 26, 2025
Renewal
Date: Aug 26, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including issues with the quality management plan, food labeling and storage, combustible storage near heat sources, staff training for transportation, medication administration errors, medication labeling inaccuracies, missing medications, medication record discrepancies, failure to follow prescriber's orders, and incomplete resident support plans. Plans of correction were accepted and implemented for all deficiencies.
Citations (11)
Quality management plan did not address reportable incidents and complaint procedures.
Unlabeled and undated leftover food items found in resident lounge refrigerators, kitchen freezer, and pantry.
Combustible materials (washcloth and dryer sheets) found near dryers in laundry rooms.
Staff transporting residents had not completed required new hire direct care staff training.
Medication administration error: resident was administered incorrect dosage of drops (6 drops instead of 5).
Discontinued medications were kept in the medication cart.
Pharmacy label for resident's PRN medication did not match medication order regarding administration frequency.
PRN medications were not available in the medication cart as ordered.
Medication administration record did not indicate the correct number of drops to be instilled.
Failure to follow prescriber's orders for medication dosage and administration times; repeat violation.
Resident support plan was not finalized within required timeframe.
Report Facts
Residents Served: 72
Total Daily Staff: 73
Waking Staff: 55
Current Hospice Residents: 1
Inspection Report — Jun 24, 2025
Date: Jun 24, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 62
Waking Staff: 47
Resident Support Staff: 0
Residents Served: 62
Residents Age 60 or Older: 62
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Current Hospice Residents: 0
Inspection Report — Jun 12, 2025
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of the inspections conducted on 06/12/2025, 06/13/2025, and 06/23/2025.
Report Facts
Total Daily Staff: 63
Waking Staff: 47
Residents Served: 62
Have Mobility Need: 1
Are 60 Years of Age or Older: 62
Inspection Report — Mar 10, 2025
Follow-Up
Date: Mar 10, 2025
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility following an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The facility was found to be in compliance with the regulatory requirements related to the initial resident assessment.
Citations (1)
The home did not complete an initial Resident Assessment Support Plan for a resident within 15 days of admission.
Report Facts
Residents Served: 62
Total Daily Staff: 62
Waking Staff: 47
Inspection Report — Feb 11, 2025
Follow-Up
Date: Feb 11, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident involving a resident elopement and support plan documentation.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing resident elopement prevention and accurate documentation of medical support plans. Corrective actions included staff re-education, audits, and updated policies to ensure resident safety and compliance.
Citations (2)
Resident elopement incident where a resident was found outside without a coat in cold weather due to a triggered wander guard alarm.
Resident's support plan did not document the use, risks, and safety related to a bedside mobility device as required.
Report Facts
Residents Served: 60
Total Daily Staff: 60
Waking Staff: 45
Current Residents in Hospice: 0
Residents Age 60 or Older: 60
Residents with Physical Disability: 1
Inspection Report — Dec 19, 2024
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 69
Waking Staff: 52
Residents Served: 68
Current Residents Hospice: 1
Inspection Report — Oct 1, 2024
Renewal
Date: Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to determine compliance with regulatory requirements and to verify the implementation of the submitted plan of correction.
Findings
Multiple deficiencies were identified during the onsite inspections on 10/01/2024 and 10/03/2024, including issues with carbon monoxide detector battery labeling, sanitary conditions related to glucometer contamination, outdated food, fire extinguisher inspections, fire drill timing, exit signage, annual medical evaluations, medication storage and administration, resident assessments, and support plan documentation. All deficiencies had accepted plans of correction with completion dates and were implemented by mid-November 2024.
Citations (12)
Carbon monoxide detector batteries were not labeled with the last change date as required.
Glucometers were used on incorrect residents, creating contamination risks.
A dented can of cheese was found in the kitchen dry storage area.
Fire extinguishers were past their annual inspection date.
Fire drill during sleeping hours was conducted at 10:45pm instead of between 12am and 6am.
Exit doors in the kitchen lacked proper exit signage initially.
Resident #1 lacked a completed annual medical evaluation document.
Medication found loose on chair in resident room; medication not administered correctly.
Expired medication drops found for Resident #2; unidentified pill found loose in medication cart.
Prescriber's orders were not followed correctly for Residents #6 and #7 regarding medication administration and holding.
Resident #8's initial assessment was completed late, exceeding 15 days from admission.
Resident #9's support plan did not document the need for a bed shaker alert during emergencies.
Report Facts
Residents Served: 66
Total Daily Staff: 66
Waking Staff: 50
Deficiency Count: 12
Inspection Report — May 14, 2024
Plan of Correction
Date: May 14, 2024
Visit Reason
The inspection was conducted as a partial, unannounced incident review on 05/14/2024, followed by a plan of correction submission and document review.
Findings
The facility was found to have a deficiency where Resident #1 did not have an annual medical evaluation completed in 2023. The submitted plan of correction was accepted and fully implemented by 06/26/2024.
Citations (1)
Resident #1 failed to have an annual health evaluation completed in 2023.
Report Facts
Residents Served: 73
Current Hospice Residents: 1
Residents Age 60 or Older: 73
Residents with Mobility Need: 3
Inspection Report — Oct 3, 2023
Renewal
Date: Oct 3, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility on 10/03/2023 and 10/04/2023 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection identified multiple deficiencies including sanitary conditions related to blood glucose monitoring equipment sharing, hot water temperature exceeding regulatory limits, incomplete medical evaluation documentation, medication labeling errors, inaccurate medication records, and delayed resident assessment documentation. Plans of correction were accepted and implemented with follow-up audits planned.
Citations (6)
Resident #2's glucometer was used on Resident #3 and Resident #3's glucometer was used on Resident #2, violating sanitary conditions.
Hot water temperature of 141°F was measured in the bathroom of room 110, exceeding the maximum allowed 120°F.
Medical evaluation for Resident #4 lacked documentation of weight, pulse rate, blood pressure, and temperature.
Medication label for Resident #1's prescription indicated incorrect dosage information.
Resident #1's medication record contained inaccurate blood glucose level transcription.
Resident #5's initial assessment was finalized more than 15 days after admission.
Report Facts
Residents Served: 71
Hot Water Temperature: 141
Hot Water Temperature Audit: 117
Inspection Report — Jul 19, 2022
Renewal
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified deficiencies related to medication administration, prescription currency, and storage procedures. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (3)
Medication administration procedures were not properly followed; a medication cup with a pill was left for a resident to take later without proper supervision.
Resident had a medication order that was still in the medication cart and was not administered as ordered.
Errors in documentation related to medication storage and administration by trained staff; medication technician documented units incorrectly.
Report Facts
Residents Served: 71
Total Daily Staff: 71
Waking Staff: 53
Inspection Report — Jun 15, 2022
Routine
Date: Jun 15, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Apr 12, 2022
Routine
Date: Apr 12, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Aug 18, 2021
Renewal
Date: Aug 18, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Wesley Village facility to review compliance with licensing requirements.
Findings
The report found deficiencies related to staff orientation and training, including incomplete initial orientation and annual training topics, as well as issues with medication equipment calibration. All deficiencies had accepted plans of correction which were fully implemented by the time of the follow-up.
Citations (4)
Staff person A did not receive orientation on fire safety and emergency preparedness topics #1 through #3 on their first day of work.
Staff person A did not complete required training in topics #1 through #7 within 40 scheduled working hours.
Direct care staff persons A, B, C, D, and E did not receive training in instructions on meeting the needs of residents during training year 2019.
Resident #1, #2, #3, and #4's glucometers were not calibrated to the correct date and time.
Report Facts
Residents Served: 70
Total Daily Staff: 70
Waking Staff: 53
Current Hospice Residents: 1
Notice — Jul 21, 2021
Date: Jul 21, 2021
Visit Reason
The document serves as a renewal notification for the operation of Wesley Village Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it is a license renewal letter and certificate of compliance confirming the facility's authorized capacity and licensing status.
Report Facts
Inspection Report — May 3, 2021
Routine
Date: May 3, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/03/2021 and 05/04/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 18, 2021
Renewal
Date: Mar 18, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/18/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 21, 2020
Renewal
Date: Oct 21, 2020
Visit Reason
The inspection was conducted as part of licensing inspections on multiple dates in October 2020 to assess regulatory compliance of Wesley Village.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on 10/01/2020, 10/02/2020, 10/09/2020, and 10/21/2020.
Notice — Jun 10, 2020
Date: Jun 10, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for Wesley Village Personal Care Home. It informs the facility that a regular license has been issued and that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms receipt of the renewal application and issuance of a regular license with a reminder of upcoming annual inspection requirements.
Report Facts
Notice — May 16, 2019
Date: May 16, 2019
Visit Reason
The document is a renewal notification and license issuance for Wesley Village Personal Care Home following receipt of a renewal application dated May 16, 2019.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Inspection Report — May 2, 2019
Annual Inspection
Date: May 2, 2019
Visit Reason
The visit was the Department’s Bureau of Human Services Licensing annual inspection of Wesley Village to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with applicable regulations, and a regular license is being issued.
Inspection Report — May 12, 2018
Renewal
Date: May 12, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Department of Human Services Bureau of Human Services Licensing for Wesley Village on May 12, 2018.
Findings
Two violations of 55 Pa. Code Chapter 2600 were found related to medication administration and following prescriber directions. Plans of correction were submitted with partial implementation and ongoing monitoring.
Citations (2)
Regulation 2600.185(a): The home did not properly maintain the medication administration record for a resident due to staff incorrectly transcribing a blood glucose test result.
Regulation 2600.187(d): The home did not follow the directions of the prescriber when a resident received 2 units of insulin instead of the prescribed 1 unit.
Report Facts
Number of Residents Served: 81
Number of Current Hospice Residents: 1
Number of Residents 60 Years of Age or Older: 60
Total Daily Staff: 81
Waking Staff: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Dzanis | Administrator | Named in plan of correction and signature on violation report |
| Gerald Dumas | Department representative conducting inspection | |
| Jason Harvey | Department representative conducting inspection |
Inspection Report — May 10, 2018
Renewal
Date: May 10, 2018
Visit Reason
The document is a renewal application and license issuance for Wesley Village Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of the facility's authorized capacity.
Report Facts
Inspection Report — May 12, 2017
Renewal
Date: May 12, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on May 12 and May 15, 2017, for Wesley Village Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including medication errors, safety issues with fire drills and carbon monoxide detectors, sanitary conditions, and labeling of medications. Plans of correction were submitted and partially implemented as of June 23, 2017.
Citations (14)
Regulation 2600.16(c): The home failed to report a medication error involving Peroxide mouth wash not administered as ordered from 5/11-5/14/17 within 24 hours to the Department.
Regulation 2600.18: The carbon monoxide detector was not located at least 15 feet from the fossil fuel burning device as required by standards.
Regulation 2600.85(a): Residents #2, #3, and #4 had dried blood on their glucometers, indicating unsanitary conditions.
Regulation 2600.132(g): Fire drills were not held on different days of the week, at different times of day and night, and not routinely held when resident attendance was low.
Regulation 2600.133(a)(1): Exit signs were missing in the residents' dining room, failing to indicate exits clearly.
Regulation 2600.182(c): Resident #5's medication was left in a cup in the resident room and not administered as ordered by the prescriber.
Regulation 2600.183(b): Resident #6's omeprazole liquid was not properly secured; the key to the lock box was chained to the box.
Regulation 2600.183(e): Resident #7's Advair Diskus inhaler was not labeled with the date it was opened, contrary to manufacturer instructions.
Regulation 2600.184(a): Resident #8's novolog flex pen lacked a pharmacy label with required information.
Regulation 2600.185(a): Resident #5's blood glucose readings were not properly documented; readings were missing or not recorded in the glucometer.
Regulation 2600.186(c): Resident #9's hydrocodone was not current on the MAR; several residents' medications were not initialed as administered on specified dates.
Regulation 2600.187(a): The medication record did not include all required information for residents' medications, including names, allergies, dosages, and administration times.
Regulation 2600.187(d): Resident #5's blood glucose readings were incomplete and not documented properly on specified dates.
Regulation 2600.188(b): Resident #1's Peroxide mouth wash was not administered as ordered and the prescriber was not notified of the medication error.
Report Facts
Number of Residents Served: 88
Number of Residents 60 Years or Older: 87
Number of Current Hospice Residents: 2
Notice — Apr 26, 2017
Date: Apr 26, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Wesley Village, a Personal Care Home, following receipt of the renewal application dated April 26, 2017.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Jul 28, 2016
Complaint Investigation
Date: Jul 28, 2016
Visit Reason
The inspection was conducted as an unannounced complaint investigation triggered by an incident reported at the facility.
Complaint Details
The complaint was substantiated. The investigation found neglect by a staff member who failed to change soiled sheets. The employee was suspended, investigated, and ultimately terminated. Mandatory abuse reports were filed with the area Agency on Aging.
Findings
A violation was found where a resident was found sleeping in a bed with fecal soiled sheets covered by a bed protector, causing an offensive odor. The facility initiated an investigation, suspended the involved employee, and terminated the employee after concluding willful neglect of resident needs.
Citations (1)
55 Pa.Code §2600.42(c): A resident was found sleeping in a bed with fecal soiled sheets covered by a bed protector, which caused an offensive odor through the night.
Report Facts
Number of Residents Served: 69
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 4
Residents 60 Years or Older: 67
Residents with Intellectual Disability: 2
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Ritsick | RN/PC Administrator | Administrator who conducted investigation and signed plan of correction |
Inspection Report — Jun 28, 2016
Complaint Investigation
Date: Jun 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident regarding the inoperability of the fire alarm system at Wesley Village Personal Care Home.
Complaint Details
The complaint investigation was triggered by an incident concerning the fire alarm system's inoperability. The Department Representative found the system showed a 'TROUBLE' signal on June 28, 2016. The Administrator and Plant Operations Director disputed the violation, providing evidence and correspondence to support that the system was operational and the trouble signal was due to construction. The complaint was not substantiated as the system was verified to be functioning properly during fire drills and inspections.
Findings
The inspection found a violation of 55 Pa.Code Chapter 2600 related to the fire alarm system being inoperative. The home's fire annunciator panel showed a 'TROUBLE' signal, but the Administrator and Plant Operations Director disputed the violation, stating the system was operational and the trouble was due to ongoing construction.
Citations (1)
55 Pa.Code 2600.130(g) requires that if a smoke detector or fire alarm becomes inoperative, repair must be completed within 48 hours. The home's fire annunciator panel indicated 'trouble' and it could not be determined if the system was fully operational.
Report Facts
Number of Residents Served: 64
Total Daily Staff: 64
Waking Staff: 48
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 1
Number of Residents Age 60 or Older: 64
Number of Residents with Intellectual Disability: 1
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Ritsick | Administrator, RN | Named in relation to the fire alarm system violation and plan of correction |
| Gerald Dumas | Department Representative conducting the inspection |
Inspection Report — May 20, 2016
Renewal
Date: May 20, 2016
Visit Reason
The inspection was an annual licensing renewal inspection conducted by the Pennsylvania Department of Human Services on May 20, 2016, for Wesley Village, a Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including delays in reviewing resident insulin administration records, failure to issue resident refunds timely, expired hospice license, improper storage of poisonous materials, unsafe conditions in facility areas, missing emergency procedure postings, inoperable smoke detectors, and incomplete medical evaluations. Plans of correction were partially implemented with adequate progress noted.
Citations (13)
Regulation 2600.5(a)(1): Department representatives were delayed in timely reviewing a resident's insulin checks and administration records due to issues with the home's electronic system.
Regulation 2600.28(f)(2): Two residents did not receive their refunds within the required 30-day period after discharge.
Regulation 2600.29(b)(11): The resident receiving hospice services was under an expired hospice license from February 1, 2014 to January 31, 2015.
Regulation 2600.82(a): A half-filled bottle labeled 'alcohol' was found in a resident's room not stored in its original labeled container.
Regulation 2600.88(a): Sections of metal ceilings and covered parking area panels were loose and potentially hazardous to residents.
Regulation 2600.91: Posted emergency telephone numbers in resident rooms were not visible due to resident furniture placement and coverings.
Regulation 2600.130(h): The home's smoke detector policy did not specify who conducts fire watch or how often during emergencies.
Regulation 2600.141(a)(1): A resident did not have a completed medical evaluation by a physician within 60 days prior to admission or within 30 days after admission.
Regulation 2600.187(a): The home failed to maintain medication administration records with required details including staff signatures and administration times.
Regulation 2600.225(a): A resident did not have a written initial assessment documented within 15 days of admission.
Regulation 2600.227(a): A resident requiring personal care services did not have a written support plan developed and implemented within 30 days of admission.
Regulation 2600.277(a): The facility did not maintain a plan of correction for a previous violation and did not assure compliance with required forms.
Regulation 2600.185(b): The home's controlled substances count policy was not consistently followed, with missing signatures and incomplete narcotic counts.
Report Facts
Number of Residents Served: 69
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Ritsick | RN, Legal Entity Representative | Named in multiple findings and signed plans of correction throughout the report. |
| Gerald Dumas | Department representative conducting the inspection. |
Notice — May 17, 2016
Date: May 17, 2016
Visit Reason
The document serves as a renewal notification and license issuance for Wesley Village Personal Care Home, confirming receipt of the renewal application and advising that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with a certificate of compliance.
Inspection Report — Jan 21, 2016
Complaint Investigation
Date: Jan 21, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident falling out of bed during a transfer on December 14, 2015.
Complaint Details
The investigation found that resident #1 fell out of bed during a transfer on 12/14/2015 at 5:30 AM. The fall occurred during a fire drill, which was cancelled as a result. The incident was not reported as required. The plan of correction was partially implemented with adequate progress as of 4/2/2016.
Findings
The facility failed to report the incident of a resident falling out of bed during a transfer within 24 hours as required by regulation 55 Pa.Code Chapter 2600. The resident was found on the floor during a fire drill, which was subsequently cancelled due to the fall.
Citations (1)
Regulation 55 Pa.Code §2600.16(c) requires the home to report incidents to the Department within 24 hours. The facility failed to provide all required information regarding a resident falling out of bed during transfer on 12/14/2015.
Report Facts
Number of Current Hospice Residents: 1
Number of Residents 60 Years or Older: 63
Number of Residents with Intellectual Disability: 1
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Ritsick | Administrator | Named as facility administrator in relation to inspection |
| Duane Valence | Department representative on-site during inspection | |
| Danielle Janoski | Legal Entity Representative | Signed plan of correction and related documents |
| Anne Graziano | Regional Licensing Administrator | Signed inspection notification letter and plan of correction approval |
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