Inspection visit

Health inspectionJanuary 8, 2024

WESLEY ENHANCED LIVING PENNYPACK PARKCMS #3954137 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Based 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. Further review of the nursing assessment tool revealed the average or range of residents with behavioral health needs was twenty-five. Review of Resident R106's clinical record revealed the resident was admitted to the facility, from the hospital, on November 8, 2023, with a diagnosis of dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities) with other behavioral disturbance. Review of Resident R106's comprehensive care plan dated November 21, 2023, revealed the resident had diminished communications and cognitive abilities related to diagnosis of dementia, and short-term memory loss. Resident R106 was usually understood and sometimes understands. Resident R106 was moderately impaired in decision making. Review of Resident R106's hospital records dated November 4, 2023, revealed the resident had an episode of severe agitation in the hospital on November 1, 2023, requiring Haldol (medication used to treat mental/mood disorders) and violent restraints (appears to happen when resident is with a female sitter). Behavioral health was consulted and indicated that the resident had dementia with cognitive decline and intermittent behavioral changes. Review of Resident R106's clinical record revealed a psychiatric evaluation dated November 15, 2023, which indicated Resident R106 believed he was admitted to the facility for mental health problems. Continued review of Resident R106's clinical record revealed on December 13, 2023, the resident began to experience increased agitation and aggression. Resident R106 was noted to be exit seeking and showing signs of physical aggression toward staff. The physician was notified and gave orders to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 395413 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 send Resident R106 to the hospital for safety and evaluation. Level of Harm - Minimal harm or potential for actual harm Further review of Resident R106's clinical record revealed a nursing note dated December 13, 2023, that the hospital was ready to discharge the resident back to the facility as the resident had no medical diagnosis for admission to the hospital and had not experienced any behaviors at the hospital. It was further noted that the Executive Director said Resident R106 could not return to the facility as the facility was not able to meet Resident R106's care requirements. Residents Affected - Few There was no indication that the facility had evaluated the resident's current treatment plan and the resident's response to that plan while he was hospitalized to determine if Resident R106 may be permitted to return to the long-term care facility. Interview on January 8, 2024, at 1:35 p.m. with the admissions director, Employee E18, confirmed the facility refused to readmit Resident R106 back to the facility after he was evaluated at the hospital. Further interview confirmed the facility did not receive or review any referral paperwork from the hospital because the facility refused to readmit Resident R106 based on aggressive behavior prior to hospitalization. 28 Pa. Code 211.12 (d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans related to respiratory care, pain management, and falls for four of twenty-four residents reviewed (Resident R97, R76, R102, and R83.) Findings Include: Review of facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident R97's medical diagnoses in the Medication Administration Record (MAR) on January 8, 2024, revealed a diagnosis for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts). Review of Resident R97's MAR for January 2024, revealed a physician's order dated November 11, 2023, for continuous positive airway pressure machine (CPAP - a machine that uses a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep) to be worn at HS (at bedtime) every day at 9:00 p.m. Observation on January 4, 2024, at 09:55 a.m., revealed that Resident R97 had a CPAP machine on the nightstand. Review of Resident R97's care plan revealed that there were no care plans available related to the resident having a CPAP or having sleep apnea. Review of Resident R76's Annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 5, 2023, revealed the resident was cognitively impaired and had a diagnosis of arthritis (joint pain, swelling, and stiffness). Further review of Resident R76's MDS, Section J- Health Conditions, revealed the resident received scheduled pain medication regimen and had reported frequent pain or hurting in the last five days. Interview on January 8, 2024, at 11:35 a.m. with Licensed Nurse, Employee E17, confirmed Resident R76 had pain related to arthritis and received topical medication for treatment. Review of Resident R76's clinical record revealed no documented evidence a comprehensive care plan was developed related to pain management. Interview on January 8, 2024, at 11:42 a.m. with the Unit Manager, Employee E9, confirmed no comprehensive care plan was developed related to pain management for Resident R76. Review of facility's Care Pans, Comprehensive Person-Centered policy, revised December 2016, states the care plan interventions are derived from a thorough analysis of the information gathered as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few part of the comprehensive assessment. The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain resident's highest practicable, physical, mental, and psychosocial well-being. Review of Resident R102's clinical records revealed medical diagnosis of high blood pressure, atherosclerotic heart disease, chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of R102's physicians orders revealed an active order placed on June 2, 2023 at 4:15pm for oxygen 2L via nasal cannula, with frequency every shift and schedule type everyday. Review of R102's care plan revealed no evidence of goals or interventions related to oxygen use. Review of facility policy titled Care Plan, Comprehensive Person Centered revised December 2016 revealed that the person-centered care plan will reflect treatment goals, timetables, and objectives in measurable outcomes; and may reflect currently recognized standards of practice for problem areas and conditions. Further review of this policy states that the interdisciplinary team must review and update the care plan when the desired outcomes are not met. Review of residents R 83s clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, abnormality of gait and mobility and dementia. A review of the Comprehensive Minimum Data Set (MDS, a periodic of the residents' assessments and care needs), dated November 30, 2023, revealed a BIMS (Brief interview for mental status- a brief screening tool that aids in detecting cognitive impairment, rated 1-15, 15 not impaired) Score of 05. Indicating that the resident R1 s cognition was impaired. Further review of Resident R 83 MDS revealed that R83 needed a one-person physical assistance with staff for transfers. Review of resident's progress notes, Resident R83 has sustained fifteen falls in the last three months. October 7,2023 at 12:04 p.m.; October 31, 2023, at 11:45 a.m.; November 7, 2023, at 7:26 a.m.; November 13, 2023, 8:00 p.m.; November 15,2023 at 3:20 pm; November 28, 2023, 10:00 am; November 28, 2023, at 4:00 p.m.; November 25, 2023, at 9:15 am; November 28,2023 at 10:00 a.m.; November 28, 2023, at 4:00 p.m.; December 1, 2023 at 2:35 p.m.; December 2, 2023 at 7:49 a.m.; December 8, 2023 at 1:45 p.m.; December 17, 2023 830 a.m.; December 29, 2023, at 1:48p.m. Review of Resident R 83's care plan revised on November 28,2023 revealed that resident R 83 had exhibited risk factors for falls related to cognitive impairment as evidence as frequent self-transferring out of bed. The goals set for this assessment is to encourage resident R83 to wear appropriate footwear (created September 11, 2023; offer assists with daily tasks (created December 2, 2023) and offer a toileting program (created December 29,2023. The interventions planned for these goals are as follows: Encourage resident R83 to participate in activities that promote exercise for strengthening and mobility created November 28, 2023. Restorative staff offer to decrease risk factors/ created October 10,2023. Therapy will offer exercise sessions to treat risk factors, created October 10, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Will keep resident in dining area vs common area to reduce stimulation, created January 1,2023. Level of Harm - Minimal harm or potential for actual harm Assists resident will all transfers, created October 20,2023. Monitor for any decline in function, Created November 7, 2023. Residents Affected - Few Wear nonskid slipper socks and nonskid footwear created November 28,2023. Staff will review safety measures with resident Created September 24,2023. Staff will observe environment for fall hazards created November 13,2023. Physical and occupational therapy consult created October 20,2023. Offer to play the radio for resident created December 8, 2023. Staff will observe fall pattern to determine whether trends can be identified and addressed created October 31,2023. All the interventions have proved to be unsuccessful evident by continued falls, the last update or revision with this care plan was December 8, 2023 with the exception of January 1, 2023 which was to keep resident in dining area vs common area to reduce stimulation, created January, this is located where the resident will not be a visible to all halls. Interview with licensed nurse, employee E 13, revealed that this employee E 13 is aware of Resident R 83s risk factors for falls. Employee E 13 recited the plan of care for Resident R83 for fall risks are to check on the resident every thirty minutes, redirect the resident, and to keep him in the common area of the floor to be more easily monitored. Employee E 13 confirmed that resident has unwitnessed frequent falls and has fallen on her shift. Resident R 83 is usually found on the ground on his knees like he is trying to crawl after trying to ambulate without any assistance or devices. 28 Pa. Code 211.10 Resident Care Policies (a) 28 Pa. Code 211.10 Resident Care Policies (c) 28 Pa. Code 211.10 Resident Care Policies (d) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that adequate personal hygiene and grooming was maintained related to incontinence care and meal administration for one out of 24 residents reviewed. (Resident R91) Residents Affected - Few Findings include: Review of facility's 'Activities of Daily Living (ADL's), Supporting,' revised March 2018, states Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care and c. Elimination, and d. Dining (meals and snacks). Review of facility provided grievance report dated October 9, 2023, revealed that on October 9, 2023 at 3:15pm, R91 was noted looking disheveled while in bed. Her daughter reported that half of a sandwich from lunch was found on her mom's bed covers. When the CNA from 3 to 11 shift provided incontinence care at 3:15 pm, dry bowel movement was found on R91. Review of statement provided by nurse aide, employee E19, assigned to care for R91 for 7 to 3pm day shift on October 9, 2023, indicates that E19 had an emergency and left facility at 1:50 pm; informing unit clerk employee E21, charge nurse - employee E17, and unit manager - employee E8. Review of statement from licensed nurse, employee E20, assigned to care for R91 on October 9, 2023 7 to 3 pm day shift, states I did not know the CNA (nurse aide) left after 13:00 o'clock. She did not notify me. Review of statement from unit clerk, E21, dated October 13, 2023 revealed that at approximately 1:30 pm nurse aide, E19, came to let her know she has to leave early. E21 instructed E19 to to speak with unit manager, E8. E21 asked charge nurse, E17 to split the assignment since she is a charge nurse and let people know. Review of statement from charge nurse, E17, dated October 11, 2023, states On October 9, 2023, I did not see the patient. She was not on my assignment. The CNA was also not on my assignment. Overall, I did not hear her say she was leaving early and she told me she informed the managers. Review of nursing schedule for October 9, 2023 day shift revealed that both licensed nurses - E17 and E20 were charge nurses for that shift. Facility did not provide coverage for R91 from 1:50 pm to 3 pm on October 9, 2023 resulting in ADL care not being done. 28 Pa Code 201.29(j) Resident rights 28 Pa Code 211.11(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policies, and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent accidents hazards for one of eight residents reviewed (Resident R 83), who sustained frequent unwitnessed falls. Findings include: Review of facility policy titled Fall Risk Assessment revised March 2018 states the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of residents R 83s clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, abnormality of gait and mobility, and dementia (Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of the Comprehensive Minimum Data Set (MDS, a periotic of the residents' assessments and care needs), dated November 30, 2023, revealed a BIMS (Brief interview for mental status- a brief screening tool that aids in detecting cognitive impairment, rated 1-15, 15 not impaired) Score of 05. Indicating that resident R83s cognition was impaired. Further review of Resident R 83 MDS revealed that R83 needed a one-person physical assistance with staff for transfers. A review of Resident R 83's care plan revised on November 28,2023 revealed that resident R 83 had exhibited risk factors for falls related to cognitive impairment as evidenced as frequent self-transferring out of bed. Further review of residents R83 care plan revealed a plan of intervention created October 31,2023 that staff will observe resident R83s fall patterns to determine whether trend can be identified and addressed as well as staff will observe and monitor Residents environment for fall or trip hazards created November 13, 2023. A review of facility's record of grievances revealed a [NAME] Concern Form dated November 20, 2023, filed by residents R 83s family member revealed concerns that resident R83 has been placed in the common areas to be better monitored, this investigation confirmed that Resident R 83 is often in the common area to be monitored for fall prevention. The area is visibly from all four hallways and staff can monitor better. Observation of first floor nursing unit common area on January 4, 2023, at 09:40 a.m. revealed twelve residents eating watching a movie on the television. There was no staff in the common area at that time. Observation of first floor nursing unit common area on January 5 ,2023 at 1:25 p.m. revealed eight residents seated in chairs and wheelchairs watching a movie on television. There was no staff in the common area at that time. Observation of first floor nursing unit common area on January 8,2023 at 11:35a.m. revealed three residents seated in the common area. There was no staff in the common area at that time, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with licensed nurse Employee E13 on January 8, 2023, at 11:40 on the first-floor nursing unit revealed that Resident R 83 is a fall risk and is usually in the common area to be monitored. Employee E 13 stated that she has been on the floor during some of the fall incidents. She denies seeing him fall. Review of the facility's fall reports for resident R 83 over the last three months revealed that Resident R 83 has sustained fifteen falls. The investigations report that thirteen of these falls occurred in the common area and only two were witnessed by staff. 28 Pa. Code 211.10 (a)(b) Resident Care Policies Nursing services 28 Pa. Code 211.12 (d)(3) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely notification of the physician for one of eight residents reviewed. (Resident R20). Residents Affected - Few Findings include: Review of the facility's policy titled Weight Assessment and Intervention Policy revised 2008 revealed that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The policy also states that the dietitian will respond within 24 hours of receipt of written notification. Review of resident R 20's clinical record revealed that Resident R20 was admitted to the facility November 28,2023 with diagnosis's of hemiplegia( a symptom that involves one sided paralysis effect either the right side or left side of the body) and hemiparesis(muscle weakness on one side of the body that effects arms , legs , and facial muscles) , dementia((a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (a medical term for difficulty swallowing). Review of weight record for resident R20 revealed on November 28,2023 resident weight 218.2 lbs weight on Hoyer scale (a lift or scale that is used to weigh bed-ridden or non-ambulatory patients), December 7, 2023, resident R20' weight was recorded as 217.0 lbs. n a Hoyer scale; December 14, 2023 resident R 20's weight was recorded as 218.0 lbs. on Hoyer scale; December 22, 2023, resident R 20's weight was recorded as 217.0 lbs. on Hoyer scale; January 2, 2023 resident R20's weight was recorded as 209.4 lbs. on Hoyer scale. Resident R 20 had a 7.6 lb. weight loss in two weeks. Review of Resident R20's care plan revealed that resident R20 has nutrition needs related to recent stroke, which included goals that the resident will consume foods at level of comfort, will maintain adequate hydration status and tolerating the current diet without difficulty chewing or swallowing. Interventions of these goals included to monitor weights, which was created on November 29,2023. Interview with dietitian Employee E 5 on January 5,2023 at 10:20a.m. revealed that she was aware of the resident's weight loss, confirmed that resident had initially had a significant weight loss when she entered the facility but since stabilized until the recent week. Employee E 5 stated that she will have resident E5 reweighed for accuracy and will address this at the weekly staff meeting. Review of resident R 20's clinical record on January 8, 2023, revealed resident R 20 had no updated weights in her chart. The facility failed to monitor and address Resident R 20's weight loss in a timely manner. 28 Pa. Code 211.6 Dietary services 28 Pa. Code 211.12 (d)(1) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure a licensed pharmacist conducted a medication regimen review at least monthly for two of five residents reviewed (Resident R62 and R3). Findings Include: Review of the undated facility policy Consultant Pharmacist and Reports revealed the consultant pharmacist will review the medication regimen of each resident at least monthly and submit a written report of findings and recommendations resulting from the review. Interview on January 4, 2024, at 2:30 p.m. with the Nursing Home Administrator, Employee E1, surveyor requested the last six months (July 2023 through December 2023) of monthly medication regimen reviews that were completed by the consultant pharmacist for Resident R62 and R3. Review of Resident R62's clinical record revealed the resident was admitted to the facility on [DATE]. Further review of clinical record revealed no documented evidence the pharmacist completed a medication regimen review for the month of December 2023. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE]. Further review of clinical record revealed no documented evidence the pharmacist completed a medication regimen review for August, October, November, or December 2023. Interview on January 8, 2024, at 9:18 a.m. with Medical Records, Employee E7, confirmed there were no other medication regimen reviews available for review for Residents R62 and R3. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Enhanced Living Pennypack Park 8401 Roosevelt Boulevard Philadelphia, PA 19152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure that an as needed psychotropic medication was limited to 14 days, without a documented rationale for continued use for one of five residents reviewed (Resident R3). Findings Include: Review of facility policy Antipsychotic Medication Use, revised December 2016, revealed residents will not receive PRN (as needed) doses of psychotropic medications (can treat a persons mood, behavior, perception, and thoughts) unless that medication is necessary to treat a specific condition that is documented in the clinical record. Further review of the policy revealed the need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale and duration for the extended order. Review of Resident R3's quarterly Minimum Data Set (federally mandated resident assessment and care screening) dated October 24, 2023, revealed the resident had a diagnosis of dementia (caused by damage to or loss of nerve cells and their connections in the brain - affects memory, thinking and social abilities) and depression (persistent sadness and loss of interest in previously enjoyable activities). Review of Resident R3's physician orders revealed an order dated February 7, 2023, for Ativan 0.5 milligrams (mg) every four hours as needed for anxiety. There was no stop date or duration specified in the order. Further review of Resident R3's clinical record revealed no documented evidence the practitioner documented the rationale and duration for the extended order. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395413 If continuation sheet Page 11 of 11

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0626GeneralS&S Dpotential for harm
F626 - Transfer and discharge-
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

FAQ · About this visit

Common questions about this visit

What happened during the January 8, 2024 survey of WESLEY ENHANCED LIVING PENNYPACK PARK?

This was a inspection survey of WESLEY ENHANCED LIVING PENNYPACK PARK on January 8, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WESLEY ENHANCED LIVING PENNYPACK PARK on January 8, 2024?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 8, 2024