F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review and staff interview, it was determined that the facility failed to
develop and implement a comprehensive person-centered care plan for identified resident problems for one
for eight residents (Resident R1).
Findings include:
Review of facility policy Care Plans, Comprehensive Person-Centered dated 1/31/23, indicated that a
comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the
resident's physical, psychosocial and functional needs is developed and implemented for each resident.
A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with
diagnoses that include Dementia(condition characterized by progressive or persistent loss of intellectual
functioning), diabetes mellitus (disease in which the body ' s ability to produce or respond to the hormone
insulin is impaired) and bipolar (psychiatric illness characterized by both manic and depressive episodes).
A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated
4/10/24, indicated diagnoses remained current.
A review of wandering risk assessment dated [DATE] indicated Resident R1 was at moderate risk for
wandering.
A review of Resident R1's current care plan was not updated to reflect wandering risk.
During an interview on 6/11/24 at 1:30 p.m. Nursing Home Administrator confirmed the facility failed to
update and develop a comprehensive care plan for Resident R1.
28 Pa Code: 211.12(d)(1)(5) Nursing services.
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 2
Event ID:
396056
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
396056
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
William Penn Care Center
2020 Ader Road
Jeannette, PA 15644
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
review of facility policy, clinical record review and staff interview, it was determined that the facility failed to
develop and implement a comprehensive person-centered care plan for identified resident problems for one
for eight residents (Resident R1).
Findings include:
Review of facility policy Incident/accident reporting dated 1/31/23, indicated to maintain resident safety in
the least restrictive manner.
A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with
diagnoses that include Dementia(condition characterized by progressive or persistent loss of intellectual
functioning), diabetes mellitus (disease in which the body's ability to produce or respond to the hormone
insulin is impaired) and bipolar (psychiatric illness characterized by both manic and depressive episodes).
A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated
4/10/24, indicated diagnoses remained current.
Review of Resident R1's wandering risk assessment dated [DATE] indicted low risk.
Review of nurse progress note dated 5/22/24 indicated Resident R1 was knocking on door, resident was
assisted back into the building and to her room, assessed by nurse, no injuries noted. Resident unable to
say what happened, notification made to son, physician and Director of Nursing (DON). No new orders.
Review of facility provided documents dated 5/22/24, resident was outside sitting with a few other
resident's, receptionist locked the door at 8:00 p.m. for the evening. Staff heard Resident R1 knocking on
door.
During an interview on 6/11/24 at 1:30 p.m. Nursing Home Administrator confirmed the facility failed to
provide adequate supervision for prevention of a potential accident for Resident R1.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396056
If continuation sheet
Page 2 of 2
