West Chester Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 6, 2024

  Based on a review of established guidelines for Cardiopulmonary Resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident 288), creating a situation in which the residents were placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation. […]

• Immediate jeopardy, isolatedF689Jun 16, 2023

  Based on observations, review of the clinical record, facility documentation, and policy and procedures, as well as staff interviews, it was determined that the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent elopement (unauthorized leave from a safe area) of a resident (Resident 27) assessed to be at risk for eloping and who successfully left the building without staff knowledge. This failure placed residents at the facility in an Immediate Jeopardy situation one for nine residents who were identified as at risk for elopement. […]

• Immediate jeopardy, isolatedF678Jan 11, 2022

  Based on a review of established guidelines for CardioPulmonary Resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident R1), creating a situation in which the residents were placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation and lack of knowledge on where to locate a resident's code status for 28 residents that had cardiopulmonary resuscitation orders. […]

• Actual harm, isolatedF755Aug 15, 2024

  Based on clinical record review and staff interview it was determined that the facility failed to ensure the pharmacy provided necessary pain medications timely which resulted in Resident 2 experiencing significant pain, and prompting emergent medical intervention. The facility failed to ensure physician ordered medications were available from the pharmacy for two of four residents reviewed (Residents 2 and 3). Findings include: Review of Resident 2's progress note of July 27, 2024, revealed resident was admitted at approximately 1:30 p.m. […]

• Actual harm, isolatedF684Jun 16, 2023

  Based on interview, observation, and clinical record review, it was determined that the facility failed to follow physician's orders for two of 33 residents reviewed (Residents 70 and 18), causing actual harm to Resident 70, who experienced a delay in obtaining treatment and services at the hospital for a urinary tract infection and septic shock. Findings include: Review of Resident 70's clinical record revealed a significant change MDS (Minimum Data Set -periodic assessment of a resident's abilities and care needs assessment dated [DATE] where resident had a BIMS (Brief Interview of Mental Status) score of 15 of 15; indicating intact cognitive function. […]