Wesley Enhanced Living Pennypack Park

Inspectors wroteBased on review of facility documentation and staff interviews it was determined that the facility failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one of 22 residents reviewed (Resident R102).

Inspectors wroteBased on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure assessments accurately reflected the resident status for one of 22 residents reviewed (Resident R13). Findings Include: Review of Resident R13's clinical record revealed the resident has documented psychotic symptoms, including hallucinations, and was prescribed psychotropic medications (drugs that affect mood, behavior, and cognition), including Risperdal, Trazodone, and Depakote. Review of Resident R13's comprehensive care plan dated June 16, 2025, revealed the resident has a history of expressing feeling down/depressed/hopeless and has a diagnosis of Major Depressive Disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of 22 residents reviewed (Resident R13). Findings Include: The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability. A Level I PASRR must be completed for all persons considering admission to a Medicaid-certified nursing facility. [...]

Inspectors wroteBased on review of resident records and interview with staff it was determined that the facility failed to review and revise a care plan for two of 22 residents reviewed (Resident R66 and R117).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure one resident environment was free from accident/hazards for one of 22 residents reviewed (Resident R63).

Inspectors wroteBased on observation staff interview the facility failed to ensure medications were stored in a secure manner for one of two medication rooms observed (First Floor).

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview it was determined the facility failed to implement enhanced barrier precautions for one of 22 residents reviewed (Resident R69).

Inspectors wroteBased on review of clinical records and review of facility provided documentation, it was determined that facility did not ensure complete documentation related to pressure ulcers treatment for one of three residents reviewed (Resident R1)

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on observations, clinical record reviews and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for two of three residents reviewed (Resident R32 and R60).

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in a language and manner they understand. Findings Include:Review of Resident R122's medical records revealed that on July 3, 2025, Resident R122 was transferred to the hospital for evaluation. Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. On June 20, 2025, Resident R122 was transferred to the hospital for an emergency evaluation. [...]

Inspectors wroteBased on the observations, review of professional standards, clinical records and interview with staff, it was determined that the facility failed to administer medications according to professional standards of practice one of three residents reviewed (Resident R32)Findings Include:According National Library of Medicine (Operated by the United States federal government, a biomedical library and a national resource for health professionals, scientists, and the public) five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices. [...]

Inspectors wroteBased on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to maintain complete and accurate inventory record for two of two residents reviewed. (Resident R12, R36)Findings Include:Review of the facility policy titled Living Reporting Grievances, last revised March 27, 2017, revealed that it is designed to ensure that each resident, responsible person, or resident agent has an opportunity to express their concern or grievance and that a system is in place for them to be heard and their concern resolved. Review of the clinical record for Resident R36, who was admitted on [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. [...]

Inspectors wroteBased on a review of facility policies, clinical records, incident/accident documents, staff training records as well as staff and resident interviews, it was determined the facility failed to ensure Resident R1 was free of neglect by failing to have sufficient staff during a mechanical lift transfer. This failure resulted in actual harm for Resident R1 who fell, sustaining multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital for one of five residents reviewed. (Resident R1).

Inspectors wroteBased on a review of facility policies, clinical records, incident/accident documents, staff training records as well as staff and resident interviews, it was determined the facility failed to ensure resident's environment remained free of accident hazards and failed to ensure safe transfer techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility failed to complete performance review of every nurse aide at least once every 12 months for one of one staff educational records reviewed. (Employee E3).

Inspectors wroteBased on staff interviews, review of facility policy and review of clinical records, it was determined that the facility failed to re-admit a resident back into the facility after a change in condition for 1 out of 5 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews and the review of clinical records, it as determined that the facility failed develop a person-centered plan of care for behaviors and refusal of medications for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that physician orders were followed and recommendations were addressed regarding obtaining labs to ensure appropriate care and services could be provided for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews and review of clinical records, it was determined that the facility failed to ensure that a recommendation for a resident to be seeen by an endocrinologist was addressed for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on observations of the physical environment of the food and nutrition services department and reviews of the pest control operator's reports it was determined that the facility failed to maintain an effective pest control program so that the building was free of pest.

Inspectors wroteBased on observations, reviewof clinical record, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for activities of daily leaving for one of 31 residents reviewed (Resident R32).

Inspectors wroteBased on review of clinical records, review of facility documentation, review ofd facility policies and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent elopement of one out of 31 residents reviewed (Resident R80).

Inspectors wroteBased on review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that physican orders were followed related to an indwelling urinary catheter for one of five residents reviewed with incontinence concerns (Resident R8).

Inspectors wroteBased on observations of nutritional care and services, interviews with staff, reviews of policies and procedures, it was determined that the facility failed to assess and monitor the nutritional status of one of four residents reviewed to ensure that each resident maintained acceptable parameters of nutritional status related to usual body weight and laboratory values. (Resident R27)

Inspectors wroteBased on observations, review of clinical records and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of 31 residents reviewed. (Resident R22)

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure provide documentation of a clinical rationale for the continued administration of an antipsychotic medication and failed to ensure that a gradual dose reduction was attempted for a psychoactive drug for one out of two residents reviewed (Residents R32) Findings Include: [...]

Inspectors wroteBased on review of clinical records, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were safely stored for one of 31 residents reviewed (Resident R36).

Inspectors wroteBased on interviews with residents and staff, reviews of policies and procedures, and clinical record reviews, it was determined that the facility failed to provide as needed dental services for one of 31 clinical records reviewed. (Resident R56)

Inspectors wroteBased on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that physician orders were accurate for one of 31 residents reviewed (Resident R32).

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Transmission Based Precautions for one of 13 residents reviewed ((Resident R8).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to ensure that residents were provided with education related to the influenza vaccines prior to administration of the vaccine for six of six residents reviewed (Residents R2, R22, R29, R36, R83 and R115)

Inspectors wroteBased on observations of the operations of the main dietary kitchen and the six kitchenettes constructed on the nursing units, reviews of manufactures' specifications for the dish machines and interviews with staff, it was determined that essential mechanical equipment used for the food and nutrition services department was not fully operational and safe.

Inspectors wroteBased on review of the nursing assessment tool, review of clinical records, and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed for hospitalizations (Resident 106). Findings Include: Review of the facility nursing assessment tool (determines what resources are necessary to care for residents during day-to-day operations and used to make decisions regarding capabilities to provide services to the residents in the facility), reviewed by the facility November 17, 2023, revealed common diagnoses include impaired cognition, mental disorder, and behavior that needs interventions. [...]

Inspectors wroteBased on review of review of clinical record, facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to report an alleged incident of neglect to the State Agency as required for one of seven clinical records reviewed. (Resident R1) Findings Include: Review of facility policy titled, Falls- Clinical Protocol last revised March 2018, states 7. Falls should also be identified as witnessed or unwitnessed events. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with a diagnoses of Raynaud's syndrome without gangrene, presence of right artificial hip joint, muscle weakness, essential hypertension, rheumatoid arthritis, Sjogren syndrome, and osteoarthritis. [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice by failing to notify a physician timely of a change in condition. (Resident R1). Findings Include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with a diagnoses of Raynaud's syndrome (blood vessels in your fingers and toes temporarily overreact to low temperatures or stress) without gangrene, presence of right artificial hip joint, muscle weakness, essential hypertension, rheumatoid arthritis, Sjogren syndrome (a long term autoimmune disease that affects the body's moisture-producing glands) and osteoarthritis. [...]