Pennsylvania Department of Health
WESLEY ENHANCED LIVING PENNYPACK PARK
Patient Care Inspection Results

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WESLEY ENHANCED LIVING PENNYPACK PARK
Inspection Results For:

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WESLEY ENHANCED LIVING PENNYPACK PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:



Based on a Revisit Survey completed on March 26, 2024, it was determined that Wesley Enhanced Living Pennypack Park, failed to correct all the state deficiencies cited during the state monitoring survey of February 21, 2024, under the requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.






 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedule, facility staffing documents and interview with staff, it was determined that the facility administrative staff failed to provide minimum ration of Nurses aide hours to residents for one of forty-five shifts reviewed. (March 22, 2024)
Findings include:

Review of staffing record from March 11, 2024 to March 25, 2024 revealed that on March 22, 2024 during the night shift, the minimum nurses aide hours required was 46.40. Further review of the facility staffing record revealed that the actual Nurse Aide hours was 45.

Telephone interview with the Director of Nursing, Employee E2 conducted on March 26, 2024 at 12:01 p.m., confirmed that the facility staffing from March 11, 2024 to March 25, 2024 did not meet the minimum state staffing requirement.





 Plan of Correction - To be completed: 04/12/2024

Plan of Correction:
P5510- The facility continues to strive to cover all open shifts with staff resident ratios of registered nurse by calling those staff members that are off duty. The facility will begin working with on-shift starting January 22, 2024 to allow staff members to view the open shifts and sign up to work those shifts. Additionally, staffing agencies will be used to fill any additional gaps in staffing. Findings and on-going monitoring of the staffing will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee.
Monitor: Unit Managers/shift Supervisor/DON/NHA
211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 review of nursing time schedule, facility staffing documents and interview with staff, it was determined that the facility administrative staff failed to provide minimum Licensed Practical Nurse (LPN) hours for sixteen of forty-five shifts reviewed. (March 11 through 25, 2024)
Findings include:
Review of the facility staffing record revealed that the following:
March 11, 2024,night shiftLPN minimum hrs. was 23.60, actual hrs was 8
March 12, 2024,night shiftLPN minimum hrs. was 23.40, actual hrs. was 8
March 13, 2024,night shiftLPN minimum hrs. was 23.40, actual hrs. was 8
March 14, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 16
March 15, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 8
March 16, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was
March 17, 2024,day shiftLPN minimum hrs. was 37.12, actual hrs. was 32
March 17, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 16
March 18, 2024,evening shift LPN minimum hrs. was 22.80, actual hrs. was16
March 19, 2024,night shiftLPN minimum hrs. was 22.8, actual hrs. was 16
March 20, 2024,night shiftLPN minimum hrs. was 22.60, actual hrs. was 16
March 21, 2024,night shiftLPN minimum hrs. was 22.60, actual hrs. was 16
March 22, 2024,night shiftLPN minimum hrs. was 22.20, actual hrs was 16
March 23, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 16
March 24, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 16
March 25, 2024,night shiftLPN minimum hrs. was 23.20, actual hrs. was 16

Telephone interview with the Director of Nursing, Employee E2 conducted on March 26, 2024 at 12:01 pm, confirmed that the facility staffing from March 11, 2024 to March 25, 2024 did not meet the minimum state staffing requirement.






 Plan of Correction - To be completed: 04/12/2024

P5530- The facility continues to strive to cover all open shifts with staff resident ratios of registered nurse by calling those staff members that are off duty. The facility has been working with on-shift starting January 22, 2024 to allow staff members to view the open shifts and sign up to work those shifts. Additionally, staffing agencies has been used to fill any additional gaps in staffing. Findings and on-going monitoring of the staffing will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee.
Monitor: Unit Managers/shift Supervisor/DON/NHA

211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on review of nursing time schedule, facility staffing documents and interview with staff, it was determined that the facility administrative staff failed to provide minimum Registered Nurse (RN) hours for seven of forty-five shifts reviewed. (March 14, 16, 17, 18, 23, 24 and 25, 2024)
Findings include:
Review of the facility staffing record revealed that during the following:
March 14, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0
March 16, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0
March 17, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0
March 18, 2024,evening shift RN minimum hrs. was 8, actual hrs. was 0
March 23, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0
March 24, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0
March 25, 2024,night shiftRN minimum hrs. was 8, actual hrs. was 0

Telephone interview with the Director of Nursing, Employee E2 conducted on March 26, 2024 at 12:01 pm, confirmed that the facility staffing from March 11, 2024 to March 25, 2024 did not meet the minimum state staffing requirement.






 Plan of Correction - To be completed: 04/12/2024

P5540- The facility continues to strive to cover all open shifts with staff resident ratios of registered nurse by calling those staff members that are off duty. The facility has been working with on-shift starting January 22, 2024 to allow staff members to view the open shifts and sign up to work those shifts. Additionally, staffing agencies will be used to fill any additional gaps in staffing. Findings and on-going monitoring of the staffing will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee.
Monitor: Unit Managers/shift Supervisor/DON/NHA


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