Heritagespring Healthcare Center of West Chester

In the surveyor’s words

From the most serious findings on record at Heritagespring Healthcare Center of West Chester, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 19, 2025

  THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication errors. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #148, when on [DATE], during admission from another long-term care facility, the facility failed to identify that pages of admission orders were missing from Resident #148's facsimiled (faxed) documents from the referring facility. […]

• Immediate jeopardy, isolatedF684Nov 25, 2024

  Based on open and closed medical record review, staff interviews, review of Emergency Medical Services (EMS) report, review of electronic monitoring device video footage, review of witness statements, review of the facility's timeline, and review of facility policy, the facility failed to ensure Resident #60 received appropriate treatment and care and medical intervention to timely treat a change in condition. This resulted in Immediate Jeopardy and serious life-threatening harm which ultimately resulted in death beginning on [DATE] at 7:40 A.M. when Resident #60, who was dependent on staff for oral intake, was being fed breakfast by Certified Nursing Assistant (CNA) #13, started coughing, became congested and eventually had white secretions from his nose and mouth impairing his airway. […]

• Actual harm, isolatedF760Aug 12, 2026

  THE FOLLOW DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUESTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review of the hospital record, review of personnel files, and policy review, the facility failed to ensure residents were free from significant medication errors. This resulted in Actual Harm to Resident #124 on 06/25/26 at approximately 11:00 P.M., when Licensed Practical Nurse (LPN) #210 administered diabetic medication Lantus (a long-acting basal insulin that provides a steady, 24-hour baseline level of insulin) 20 units subcutaneous injection in error. […]

• No harm, potential for more than minimal, isolatedF755Nov 19, 2025

  Based on record review, staff interview, facility document review, and policy review, the facility failed to ensure medication was dispensed and administered as ordered to one (#149) of six residents reviewed for unnecessary medication. The census was 126. Findings included:Review of a medical record revealed the facility admitted Resident #149 on 05/23/25. The resident had a medical history that included a diagnosis of insomnia. Further review revealed the facility discharged Resident #149 home on [DATE]. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/29/25, revealed Resident #149 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. […]

• No harm, potential for more than minimal, isolatedF755Apr 25, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview and policy review, the facility failed to ensure an accurate reconciliation and accounting of all controlled substances. This affected one (#122) out of three reviewed for medication reconciliation. The facility census was 123. Findings include: Review of the medical record for Resident #122 revealed an admission date of 02/13/25 and a discharge date of 03/15/25. […]