A list of the most recent deficiencies for William Penn Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-12-14 | 2024-01-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-30 | 2023-10-25 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-30 | 2023-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-30 | 2023-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | 2023-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-10-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-30 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-30 | 2023-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-30 | 2023-10-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-24 | 2023-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-06 | 2023-06-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-06 | 2023-06-12 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-24 | 2022-10-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-24 | 2022-10-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-24 | 2022-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-10-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-24 | 2022-10-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-24 | 2022-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-24 | 2022-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-10-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-24 | 2022-10-12 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-24 | 2022-10-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-24 | 2022-10-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-29 | 2022-10-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-29 | 2022-10-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-29 | 2022-10-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-21 | 2022-08-16 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-22 | 2022-01-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-22 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-19 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-29 | 2021-10-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-29 | 2021-10-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-29 | 2021-10-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-11 | 2021-09-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-11 | 2021-09-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-24 | 2021-07-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-24 | 2021-07-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-07-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-24 | 2021-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-24 | 2021-07-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-24 | 2021-07-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-24 | 2021-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-07-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-06-24 | 2021-07-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-24 | 2021-07-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-24 | 2021-07-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-24 | 2021-07-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-24 | 2021-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-16 | 2021-05-18 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-04-16 | 2021-05-18 | Y |
