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Deficiency Records for William Penn Care Center
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.
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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-19 | 2024-08-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-19 | 2024-08-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-19 | 2024-08-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-19 | 2024-08-19 | N |
| Respond appropriately to all alleged violations. | Health | 2024-07-19 | 2024-08-19 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2024-07-19 | 2024-08-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-07-19 | 2024-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-19 | 2024-08-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-19 | 2024-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-19 | 2024-08-19 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-07-19 | 2024-08-19 | 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 | 2024-07-19 | 2024-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-19 | 2024-08-19 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-07-19 | 2024-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-19 | 2024-08-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-19 | 2024-08-19 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-07-19 | 2024-08-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Develop a communication plan. | Fire Safety | 2024-07-17 | 2024-08-16 | 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 | 2024-07-17 | 2024-08-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-07-17 | 2024-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-17 | 2024-08-16 | 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 | 2024-06-11 | 2024-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-11 | 2024-07-15 | Y |
| 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 |
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