WESLEY ENHANCED LIVING MAIN LINE REHAB AND SKD NSG

Nursing Home Inspector

100 HALCYON DRIVE
MEDIA, PA 19063
Delaware County
Phone: 610-353-7660
Provider Number: 395498
Last Inspection: 03/20/2017

About the Nursing Home

Number of Beds: 60
Number of Residents: 53
Beds Available: 7
Percent Occupancy: 88%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

23

Facility
19

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

23

2017
22

2016
39

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/20/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 5/16/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/16/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 5/16/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 5/16/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 5/16/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 5/16/2017
 
Failed To: Quickly tell the resident's doctor the results of laboratory tests. Isolated : Minimal 3 5/16/2017
 

4/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 6/7/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 6/7/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/7/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 6/7/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/7/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Isolated : Minimal 3 6/7/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 6/7/2016
 

3/9/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 5/7/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/2/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 5/7/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/7/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/2/2015
 
Failed To: Dispose of garbage and refuse properly. Pattern : Minimal 4 5/7/2015
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 5/7/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/2/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/7/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 5/7/2015
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 6/2/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 7/5/2016
 

9/22/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/2/2015
 

8/25/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 10/1/2015
 

8/3/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 9/27/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/27/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 9/27/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 53 119.00 110.03
Registered Nurses 0.87 1.06 0.94
Licensed Practical / Vocational Nurses 0.74 0.80 0.85
Certified Nursing Assistants 1.97 2.25 2.26
Total Staff Hours 3.58 4.11 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 4 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 80 91 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 95 95
of long-stay residents experiencing one or more falls with major injury 6 4 3
of long-stay residents who have depressive symptoms 3 3 2
of long-stay residents who lose too much weight 8 7 7
of long-stay residents who received an antianxiety or hypnotic medication 27 21 22
of long-stay residents who received an antipsychotic medication 12 14 15
of long-stay residents who self-report moderate to severe pain 8 6 6
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 29 20 20
of long-stay residents whose need for help with daily activities has increased 15 16 15
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 11 3 3
of low risk long-stay residents who lose control of their bowels or bladder 70 57 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 45 76 83
of short-stay residents who had an outpatient emergency department visit 13 10 10
of short-stay residents who made improvements in function 60 62 64
of short-stay residents who newly received an antipsychotic medication 1 2 1
of short-stay residents who self-report moderate to severe pain 16 16 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 77 78 82
of short-stay residents who were rehospitalized after a nursing home admission 29 21 20
of short-stay residents who were successfully discharged to the community 44 54 52
of short-stay residents with pressure ulcers that are new or worsened 0 0 0