Nursing Investigation Results -

Pennsylvania Department of Health
WESLEY VILLAGE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WESLEY VILLAGE, THE
Inspection Results For:

There are  85 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WESLEY VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit Survey completed on December 9, 2021, it was determined that The Wesley Village corrected the federal deficiencies cited during the survey of October 29, 2021, but continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(a) Skilled Nursing Facilities
A facility-

483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with 483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.
Observations:

Based on review of clinical records and resident payor source data, and staff interview, it was determined that the facility failed to ensure that routine annual and emergency dental services were provided for four Medicare/private payor source residents out of 13 residents sampled. (Resident 7, 11, 12 and 13).

Findings include:

Review of Resident 7's clinical record revealed admission to the facility on September 27, 2019, as a private pay payor source.

A Dental Consult form was completed on February 15, 2017, which indicated that the resident had a dental exam with findings of a cracked tooth evaluated and to follow-up in 6 months.

According to dental status report from the facility's contracted dental services dated December 9, 2021, as of September 23, 2021, dental treatment remained pending for Resident 7, needing resident or responsible party approval.

There was no documented evidence that from September 23, 2021, to the survey of December 9, 2021, the facility had secured the necessary follow-up for necessary dental services to be provided to Resident 7. The facility was unable to evidence that the resident had received dental services since February 15, 2017.

Review of Resident 11's clinical record revealed admission to the facility on April 29, 2016, as a Medicare payor source.

According to dental status report dated December 9, 2021, as of October 28, 2021, dental treatment was pending for Resident 11 requiring the resident or responsible party approval. There was no documented evidence that from October 28, 2021, to the time of the survey of December 9, 2021, that the facility had completed the follow-up steps necessary for dental services to be provided to Resident 11.

Review of Resident 12's clinical record revealed admission to the facility on September 11, 2021, as a Medicare payor source.

Review of dental consult performed on November 23, 2021, revealed that Resident 12 had moderate plaque and calculus, root concerns with tooth #19, and that the resident was not interested in dentures. Dental Recommendations included that the resident be referred to dental hygiene and extract tooth #19.

According to the dental status report dated December 9, 2021, as of November 24, 2021, the recommended dental treatment was pending for Resident 12, requiring resident or responsible party approval. Review of the dental status report revealed that treatment remained outstanding for adult prophylaxis (cleaning), surgical removal of tooth #19, and perapical x-ray. There was no documented evidence that the facility had secured the necessary follow-up to ensure that resident 12 received the recommended dental services in a timely manner.

Review of Resident 13's clinical record revealed admission to the facility on December 31, 2020, as a Medicare payor source.

According to dental status report dated December 9, 2021, as of October 28, 2021, dental treatment was pending, needing resident or responsible party approval. There was no documented evidence that from October 28, to December 9, 2021, the facility had completed the necessary follow-up for Resident 13 to receive dental services.

Interview with the Nursing Home Administrator on December 9, 2021 at approximately 2:00 p.m. revealed that the facility does not review the dental consult sheets and does not follow-up with the recommendations from the dentist. The NHA further stated that the dental consult forms are uploaded into the resident's electronic medical record and it is the responsibility of the facility's contracted dental office to contact the resident or the resident and/or residents' family regarding services. The NHA confirmed that he was not aware of the outstanding dental recommendations or residents' need for dental services prior to surveyor inquiry on December 9, 2021.



28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

28 Pa. Code 201.21 (b)(c) Use of outside resources

28 Pa Code 211.15(a) Dental services

28 Pa. Code 201.18 (e)(3) Management





 Plan of Correction - To be completed: 01/25/2022

Wesley Village submits that its policies, systems, and procedures related to resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this plan of correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey, Wesley Village did have policies, procedures and systems in place to maintain compliance with federal and state requirements; however, in an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
Facility cannot address this as it relates to Resident 7. as resident was discharged from the facility on 12/11/21.
The facility cannot correct this as it relates to Resident 11, as this resident was discharged from facility on 10/31/21.
Resident 12 was seen by a Hygienist on 12/14/21 and received prophylaxis treatment
Resident 13's daughter was waiting on MA to be approved. Consent received on 12/11/21 and resident is scheduled to see the dentist on 12/30/21.
All facility residents who are Medicare/private pay will be evaluated by the facility contracted or personal dentists by 1/24/2022 to ensure they receive their routine annual visits and have initiated emergency dental services. All necessary appointments have been scheduled. All residents through these appointments with newly identified dental needs will have new appointments schedule for follow-up by 1/24/2022.
The Nursing Secretaries will be provided with a scheduling tool and be educated by 12/31/2021 on the necessity to track dental consults in addition to the scheduling conducted by the contract dental company. In addition, all dental consults will be reviewed by the ADON to ensure appropriate follow-up.
The facility QAPI Team has audited 100% of Medicare/private pay residents to ensure they received or are scheduled for their routine annual exam and have initiated existing emergency dental services as desired by the resident or and/or the Resident Representative. In addition, they will audit to ensure all newly identified dental needs have appointments established to address identified issues.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on review of clinical records and resident payor source data, and staff interview, it was determined that the facility failed to ensure that routine annual and emergency dental services were provided for four Medicaid payor source residents out of 13 residents sampled. (Resident 3, 8, 9, and 10).

Findings include:

Review of the clinical record of Resident 3 revealed admission to the facility on December 27, 2019. The resident's payor source was Medicaid.

According to dental status report received from the facility's contracted outside dental services dated December 9, 2021, as of October 11, 2021 adult prophylaxis treatment was approved for Resident 3. However, there was no evidence that the resident received the adult prophylaxis service as of December 9, 2021.

Review of a dental consult dated November 23, 2021, revealed that Resident 3 had loose teeth, numerous root concerns, and that she would like dentures. Consult Recommendations included to extract all loose teeth, extract all roots, and apply for full upper and full lower dentures. Further review of the consult revealed that the resident required an appointment in the dental office for extractions.

Further review of the dental status report dated December 9, 2021, revealed that the recommendations made during the dental consult on November 23, 2021, remained pending resident or responsible party approval. There was no documented evidence that the facility had conducted the necessary follow-up to secure the recommended dental services for Resident 3.

Review of the clinical record of Resident 8 revealed admission to the facility on October 11, 2019. The resident ' s payor source was Medicaid.

Review of dental consult dated November 3, 2021 revealed that the resident was not available for an exam and it was to be rescheduled.

Review of dental consult performed for Resident 8 on November 23, 2021, revealed that her full upper and full lower dentures were in fair condition. The full upper denture was cracked with recommendation for the full upper denture to be picked up for repair.

According to dental status report dated December 9, 2021, the resident's full upper dentures and a periodic exam were approved by the resident and/or responsible party as of November 24, 2021.

There was no documented evidence that the necessary dental services had been scheduled/arranged/provided to the resident as of December 9, 2021.

Review of Resident 9's clinical record revealed admission to the facility on April 30, 2018. The resident's payor source was Medicaid.

Review of dental consult dated November 23, 2021, revealed that Resident 9 would like upper dentures and was found to have plaque and calculus. Recommendations were to continue dental exams, follow-up with dental hygiene, x-rays for new dentures, and to remove root tips. According to the dental consult, recommendations also included a referral to dental office for extractions.

According to the dental status report dated December 9, 2021, the resident's full mouth x-ray series was approved by the resident and/or responsible party on November 24, 2021. As of November 29, 2021, a periodic exam and adult prophylaxis services were also approved.

There was no evidence that as of December 9, 2021, the facility had arranged or scheduled the resident to receive the approved dental services recommended for the resident.

Further review of the dental status report revealed that as of November 29, 2021, a dental recommendation for surgical removal of 6 teeth remained pending resident or responsible party approval. There was no documented evidence that the facility had completed the necessary follow-up steps to complete the necessary dental care for Resident 9.

Review of Resident 10's clinical record revealed admission to the facility on September 27, 2017. The resident payor source was Medicaid.

Review of dental consult dated October 6, 2021, revealed that the resident had moderate plaque and calculus with recommendations to refer the resident to dental hygiene and continue exams.

According to the dental status report dated December 9, 2021, the recommended services for periodic exams and adult prophylaxis were approved by the resident and/or responsible party. As of December 9, 2021, there was no evidence that the adult prophylaxis service recommended for the resident October 6, 2021, had been completed or scheduled.

Interview with the Nursing Home Administrator on December 9, 2021 at approximately 2:00 p.m. revealed that the facility does not review the dental consult sheets and does not follow-up with the recommendations from the dentist. The NHA further stated that the dental consult forms are uploaded into the residents' electronic medical records and it is the responsibility of the facility's contracted dental office to contact the resident or the resident's representative regarding the needed services. The NHA confirmed that he was not aware of the outstanding dental recommendations or residents' need for dental services prior to surveyor inquiry on December 9, 2021.


28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

28 Pa. Code 201.21 (b)(c) Use of outside resources

28 Pa Code 211.15(a) Dental services

28 Pa. Code 201.18 (e)(3) Management







 Plan of Correction - To be completed: 01/25/2022

Wesley Village submits that its policies, systems, and procedures related to resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this plan of correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey, Wesley Village did have policies, procedures and systems in place to maintain compliance with federal and state requirements; however, in an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
Resident 3 received prophylaxis on 12/14/21, resident had already been seen on 11/23/21 for extraction of problematic tooth. Resident and family both declined further extractions and denture fitting as remaining teeth are not causing any pain.
Resident 8 was seen on 12/14/21 by the dentist and dentures were determined to not be repairable. Resident declined being fitted for new dentures, as current dentures still fit and she has no difficulty eating.
Resident 9 was seen by Hygienist on 12/14/21 and received prophylaxis. Resident and family declined extractions and denture fitting, as resident is not having difficulty eating
Resident 10 was seen by Hygienist on 12/14/21 and received prophylaxis.
All facility residents who are Medicaid payor will be evaluated by the facility contracted or personal dentists by 1/24/2022 to ensure they receive their routine annual visits and have initiated emergency dental services. All necessary appointments have been scheduled. All residents through these appointments with newly identified dental needs will have new appointments schedule for follow-up by 1/24/2022.
The Nursing Secretaries will be provided with a scheduling tool and be educated by 12/31/2021 on the necessity to track dental consults in addition to the scheduling conducted by the contract dental company. In addition, all dental consults will be reviewed by the ADON to ensure appropriate follow-up.
The facility QAPI Team has audited 100% of the residents who are Medicaid payor source to ensure they received or are scheduled for their routine annual exam and have initiated existing emergency dental services as desired by the resident or and/or the Resident Representative. In addition, they will audit to ensure all newly identified dental needs have appointments established to address identified issues.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port