Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pocopson Home during CMS and state inspections, most recent first.
A licensed employee on the 1 West nursing unit was observed removing medications from pill packs and placing the pills in their hand before placing them in a medication cup, without wearing gloves. The employee also did not wear gloves while administering eye medications. The DON confirmed these actions were against facility policy.
A resident was physically restrained using pajama pants tied tightly around the waist, causing harm. The facility failed to follow its policies on restraints, did not report the incident, and did not conduct an investigation. The resident's records lacked documentation for the use of restraints or the scoot chair, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a severely cognitively impaired resident exhibiting restlessness and anxiety. Despite multiple documented instances of ineffective interventions and the use of PRN medications, no care plan was created to address the resident's needs. The resident was found tied to a scoot chair, resulting in harm, and no pre-restraining assessment or proper documentation was available.
A facility failed to report and investigate allegations of abuse involving a resident who was tied to a chair with pajama pants, preventing movement. Despite witness statements from staff, no investigation was initiated, and the incident was not reported to the Department of Health. The resident's care plan did not include documentation for the use of restraints, and the facility's policy on restraints was not followed.
A facility failed to investigate an allegation of physical restraint for a cognitively impaired resident who was found tied to a chair with pajama pants. Despite witness statements, no investigation was initiated, and the incident was not reported to the Department of Health. The facility's records lacked documentation of a pre-restraining assessment, care plan for restlessness, or use of the scoot chair and restraints.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure adequate infection control measures during a medication pass observation on the 1 West nursing unit. Specifically, a licensed employee was observed removing medications from pill packs and placing the individual pills in their hand before placing them in a medication cup, without wearing gloves. Additionally, the same employee did not wear gloves while administering eye medications. The Director of Nursing confirmed that the employee should have been wearing gloves and should have placed the pills directly into the medication cup from the pill pack.
Failure to Ensure Residents Are Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints not required to treat medical symptoms, resulting in harm to a resident who was physically restrained using pajama pants tied tightly around the waist. The resident, who was severely cognitively impaired and required extensive assistance for care activities, was found tied to a rolling reclining chair, causing a reddened area on the skin. The facility's policy mandates that restraints should only be applied after obtaining a physician's order and notifying the family, which was not followed in this case. Additionally, the care plan should be updated, and the appropriate record should be initiated to track the use and release of the restraint, which was also not done. The incident was not reported to the Department of Health, and no investigation was initiated by the facility. The Director of Nursing and the Nursing Home Administrator were unaware of the incident until the Department of Health's visit. Witness statements from staff revealed that the resident was tied to the chair with pajama pants, and the restraint was not considered a restraint by the Director of Nursing, who believed it was a method to keep the resident safe from falls. However, the facility's records failed to document any pre-restraining assessment, care plan for restlessness, or use of the scoot chair. The resident's records indicated a fall risk care plan and interventions for wandering, but there was no evidence of a care plan for the use of restraints or the scoot chair. The occupational therapy treatment note documented the use of a scoot chair, but there was no care plan or assessment for its use. The facility's failure to follow its own policies and procedures regarding restraints and the lack of documentation and investigation led to the deficiency and harm to the resident.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired and exhibited restlessness and anxiety. Despite multiple progress notes documenting the resident's behaviors and the ineffectiveness of various interventions, no care plan was created to address the resident's restlessness, use of a scoot chair, restraints, or bed rails. The resident was found tied to a scoot chair with fleece pajama pants, which resulted in a reddened area on the abdomen, indicating harm due to improper restraint use. The resident's clinical records revealed multiple instances of restlessness and attempts to get out of bed or walk around, with staff interventions such as redirection, toileting, snacks, and fluids proving ineffective. The resident was also given PRN medications like Lorazepam and Morphine, which had little success in managing the behaviors. Despite these documented issues, the facility did not have a care plan in place to address the resident's specific needs related to restlessness and the use of assistive devices. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that no pre-restraining assessment was performed, and no restraint documentation or care plan was available for the resident. The administration believed that the staff were acting to prevent falls by tying the resident to the scoot chair, but this action was not properly documented or planned. The resident was approved for a window-side bedrail and scoot chair, yet no care plan was created for these interventions, nor for the resident's terminal restlessness condition.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving the physical restraint of a resident, identified as Resident R1. The incident involved Resident R1 being tied to a rolling reclining chair with fleece pajama pants, which prevented the resident from moving or standing up. Despite witness statements from multiple staff members, including a nurse assistant and a registered nurse, the facility did not initiate an investigation or report the incident to the Department of Health. The Director of Nursing and the Nursing Home Administrator were unaware of the incident and did not consider the act of tying the resident to the chair as a form of restraint, believing it was a method to prevent falls. Resident R1 was severely cognitively impaired, unable to make their needs known, and required extensive assistance for care activities. The resident's care plan indicated interventions for wandering and fall risk but did not include any documentation or assessment for the use of restraints. The facility's policy on restraints required a physician's order, family notification, and consent, none of which were obtained in this case. Additionally, the facility's records did not show any pre-restraining assessment or documentation for the use of the scoot chair or any other restraint for Resident R1. The incident came to light when a nurse assistant observed Resident R1 tied to the chair and reported it to a registered nurse, who then called the Licensed Practical Nurse (LPN) supervisor. The LPN supervisor found a red mark on the resident's abdomen, which resolved after the pajama pants were removed. Despite these observations and the facility's policy on restraints, no formal investigation was conducted, and the incident was not reported to the appropriate authorities. The facility's failure to report and investigate the incident constitutes a deficiency in compliance with state regulations on management and nursing services.
Failure to Investigate Allegation of Physical Restraint
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical restraint in a timely manner for a resident who was found tied to a rolling reclining chair. The facility's policy on restraints requires a physician's order, family notification, and consent, none of which were documented in this case. The resident, who was severely cognitively impaired and required extensive assistance, was found tied to a chair with fleece pajama pants, preventing movement or standing up. Despite witness statements from multiple staff members, no investigation was initiated, and the incident was not reported to the Department of Health. The Director of Nursing and the Nursing Home Administrator were unaware of the incident until the Department of Health's visit. The Director of Nursing believed that tying the resident to the chair was not considered a restraint but a method to prevent falls. However, the facility's records failed to show any documentation of a pre-restraining assessment, care plan for restlessness, or use of the scoot chair and restraints. The resident's care plan did not include any interventions related to the use of restraints or the scoot chair. The facility's failure to document and investigate the incident, as well as the lack of a pre-restraining assessment and proper care planning, led to the deficiency. The resident's records did not reflect any approved use of the scoot chair or restraints, and the incident was not reported or investigated as required by the facility's policy and state regulations.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crosslands | 1 mi | ★★★★★ | 2 | 0 |
| Kendal At Longwood | 3.6 mi | ★★★★★ | 0 | 0 |
| West Chester Rehabilitation And Healthcare Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Barclay Friends | 5.6 mi | ★★★★★ | 0 | 0 |
| Park Lane Post Acute Llc | 6.4 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.