Pennsylvania Department of Health
WESLEY ENHANCED LIVING - DOYLESTOWN
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WESLEY ENHANCED LIVING - DOYLESTOWN - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on February 21, 2025, it was determined that Wesley Enhanced Living Doylestown was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(k) REQUIREMENT Pain Management:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review and staff interview it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 13 sampled residents. (Resident 8)

Findings include:

Clinical record review revealed that Resident 8 had diagnoses that included dementia, fibromyalgia, and diabetes. On November 25, 2024, the physician ordered for the resident to receive the narcotic pain medication, oxycodone, every four hours as needed for severe, chronic pain. Review of Resident 8's care plan revealed that the resident had chronic pain and that the interventions were for staff to provide comfort measures with positioning, control noise levels, and other non-medication interventions. Review of Medication Administration Records revealed that the resident received the as needed narcotic (oxycodone) without documented evidence that non-pharmacological interventions were attempted prior to administration 62 times in January 2025 and 39 times in February 2025.

In an interview on February 21, 2025, at 10:34 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication.

28 Pa. Code 211.9(a)(1) Pharmacy services.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 04/04/2025

For Resident #8, the facility worked with its electronic medical record provider (Point Click Care) to have options to document the non-pharmacological interventions within the medication administration record, which have been added.

The facility will add non-pharmacological interventions for all residents that have as needed narcotic prescriptions by 3/7/2025.

The Director of Nursing and the Nurse Manager will train all nurses of the addition of the non-pharmacological interventions that are within the Medication Administration Record, which started on March 5, 2025.

The facility will audit on a bi-monthly basis medication administration records for residents who have narcotic as needed medications to ensure non-pharmacological interventions were attempted prior to administering the as needed narcotic. The audit will be done for the next 3 quarters.

The Plan of Correction is discussed and evaluated (for up to 3 quarters) by the Executive Director and Quality Assurance Team (QAPI) at the quarterly Quality Assurance Meetings to ensure it has been implemented and is still effective. If not effective, it will be amended, and a new Plan of Correction will be implemented and monitored to ensure the deficiency does not occur again.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from December 22 through 28, 2024, January 12 through 18, 2025, and February 14 through 20, 2025, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on the day (7:00 a.m. to 3:00 p.m.) shift on December 25, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on the night (11:00 p.m. to 7:00 a.m.) shift on December 22, 2024, and February 14 and 19, 2025.

Plan of Correction - To be completed: 02/25/2025

The facility cannot retroactively correct the staffing ratios.

The facility continues to strive to cover all open shifts. The Facility does use OnShift scheduling software that allows employees to sign up for shifts. The schedule is typically posted in OnShift at least 1 month in advance. This scheduling software also allows for text messaging when callouts occur to get coverage. Lastly, the facility continues to aggressively recruit nursing assistants.

The facility has adapted the staffing calculator with FTE that was published by the Department of Health for daily monitoring by shift and census vs. the tool that had been in use for daily monitoring by the Shift Supervisor/DON/NHA Daily.

The Plan of Correction is discussed and evaluated (for up to 3 quarters) by the Executive Director and Quality Assurance Team (QAPI) at the quarterly Quality Assurance Meetings to ensure it has been implemented and is still effective. If not effective, it will be amended, and a new Plan of Correction will be implemented and monitored.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for one of 21 days reviewed.

Findings include:

Review of nursing schedules from December 22 through 28, 2025, January 12 through 18, 2025, and February 14 through 20, 2025, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on the night (11:00 p.m. to 7:00 a.m.) shift on January 18, 2025.

Plan of Correction - To be completed: 02/25/2025

The facility cannot retroactively correct the staffing ratios.

The facility continues to strive to cover all open shifts. The Facility does use OnShift scheduling software that allows employees to sign up for shifts. The schedule is typically posted in OnShift at least 1 month in advance. This scheduling software also allows for text messaging when callouts occur to get coverage. Lastly, the facility continues to aggressively recruit Licensed Practical Nurses and/or Registered Nurses.

The facility has adapted the staffing calculator with FTE that was published by the Department of Health for daily monitoring by shift and census vs. the tool that had been in use for daily monitoring by the Shift Supervisor/DON/NHA Daily.

The Plan of Correction is discussed and evaluated (for up to 3 quarters) by the Executive Director and Quality Assurance Team (QAPI) at the quarterly Quality Assurance Meetings to ensure it has been implemented and is still effective. If not effective, it will be amended, and a new Plan of Correction will be implemented and monitored.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for two of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from December 22 through 28, 2025, January 12 through 18, 2025, and February 14 through 20, 2025, revealed the following total nursing care hours below minimum requirements:

December 25, 2024: 3.18 care hours per resident
February 16, 2025: 3.18 care hours per resident

Plan of Correction - To be completed: 02/25/2025

The facility cannot retroactively correct the staffing.

The facility continues to strive to cover all open shifts. The Facility does use OnShift scheduling software that allows employees to sign up for shifts. The schedule is typically posted in OnShift at least 1 month in advance. This scheduling software also allows for text messaging when callouts occur to get coverage. Lastly, the facility continues to aggressively recruit Certified Nursing Assistants, Licensed Practical Nurses, and/or Registered Nurses.

The facility has adapted the staffing calculator with FTE that was published by the Department of Health for daily monitoring by shift and census vs. the tool that had been in use for daily monitoring by the Shift Supervisor/DON/NHA Daily.

The Plan of Correction is discussed and evaluated (for up to 3 quarters) by the Executive Director and Quality Assurance Team (QAPI) at the quarterly Quality Assurance Meetings to ensure it has been implemented and is still effective. If not effective, it will be amended, and a new Plan of Correction will be implemented and monitored.

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