Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 West Chester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with increased weakness had a UA/C&S ordered by the NP, but nursing did not collect the urine when first ordered. The resident's guardian later expressed concern about a change in condition, and the NP reordered the urinalysis after learning it still had not been obtained. The urinalysis was later positive for gram negative rods, and Macrobid was ordered.
A resident with increased weakness had a chest x-ray ordered after staff spoke with the NP, but the x-ray was not obtained when first ordered. Later, the resident’s guardian raised concern about the resident’s health status and possible change in condition, and another chest x-ray order was placed. The NHA confirmed the x-ray was not completed until nearly two weeks after the initial order.
The facility failed to include residents or their responsible parties in the care planning process for three residents. Despite completing MDS assessments, there was no evidence that these individuals were invited to participate in their care plan meetings. This was confirmed by the Nursing Home Administrator.
The facility failed to include the required Interdisciplinary Team (IDT) in care plan meetings for 15 residents. Federal regulations mandate that care plans be prepared by an IDT, including the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff. However, the meetings were attended by limited staff, such as social services, therapy, nursing, dietary, and respiratory staff, without the full IDT participation.
The facility did not ensure that four staff members completed the required 12 hours of annual training. Documentation review and interviews confirmed the deficiency, which was previously cited under state code.
A resident with ESRD, Heart Failure, and Diabetes experienced a significant weight gain over a short period, but the facility failed to notify the physician. Despite the weight increase being identified, it was not communicated, indicating a lapse in required notification procedures.
The facility failed to follow physician orders for two residents. One resident with chronic kidney disease and hyponatremia was not monitored for fluid intake as per the physician's order, leading to excess fluid consumption. Another resident received incorrect dosages of Morphine Sulfate due to a transcription error, although no adverse effects were reported. These deficiencies were confirmed with the facility's administration.
A resident with spinal stenosis and chronic back pain was administered Oxycodone HCL 10 mg 11 times despite having a pain level rating of 0, indicating no pain. The clinical record lacked an explanation for this administration, and the issue was reported to the DON.
The facility failed to properly label and store medications on two medication carts, with insulin pens found used and undated, and loose medications scattered in drawers. Staff interviews revealed insulins were placed in zip-lock bags, and scattered medications resulted from accidental popping out from blister packages.
The facility failed to provide timely pain medications for a resident, leading to severe pain and hospital transfer. The resident, with conditions like Postlaminectomy Syndrome, did not receive prescribed MS Contin and acetaminophen due to pharmacy delays. Another resident missed doses of Donepezil, Tamsulosin, and Levetiracetam due to similar issues, as confirmed by the ADON.
A resident with a physician's order for full life-sustaining interventions, including CPR, was found unresponsive and not breathing. The RN Supervisor did not initiate CPR, citing the resident's hospice status and a conversation with the resident's daughter, despite the resident's documented full code status and facility policy requiring CPR to be initiated unless a DNR order was in place.
The facility failed to follow physician's orders for pre and post-dialysis weight monitoring and to maintain communication with the dialysis center for four residents with ESRD. Multiple instances of missing weight documentation were found, and the Nursing Home Administrator confirmed the lack of compliance.
The facility failed to ensure that CPR was provided in accordance with the facility policy and procedures for a resident who was a FULL CODE. The NHA and DON did not effectively manage the facility to ensure compliance with federal and state guidelines and regulations, resulting in the failure to administer CPR as required.
The facility failed to notify the physician of significant weight changes in two residents with ESRD and dependent on Hemodialysis. One resident had a 13.8% weight gain over five days, and another had a 29.78% weight gain over four days, with delays in notifying the physician confirmed by the DON.
A resident with severe cognitive impairment and multiple health issues experienced bilateral hip fractures of unknown origin. Despite the resident denying trauma or falls, the facility failed to conduct necessary staff interviews, leading to a deficiency in management and nursing services.
The facility did not notify the State LTC Ombudsman's office when a resident was transferred to the hospital due to being unresponsive, as confirmed by the Nursing Home Administrator.
The facility failed to develop a comprehensive care plan for a resident with Dementia, Bipolar Disorder, and Anxiety Disorder, who had a history of psychiatric hospitalizations and previous attempts to hurt self. The care plan did not address the resident's behavior related to self-harm, as confirmed by the Nursing Home Director.
The facility failed to ensure consistent wound treatment for a resident with a surgical wound and did not follow the wound consultant's recommendations. The resident's wound treatment was missed on several occasions, and a new treatment recommendation was not implemented due to a lack of communication with the physician.
A resident continued to receive an unnecessary psychotropic medication despite recommendations from a psychiatrist to taper the dose. The resident experienced increased daytime sleepiness and low energy levels, and the facility did not follow the psychiatrist's recommendations in a timely manner.
The facility failed to obtain and monitor weights for two residents, leading to significant unaddressed weight changes. Despite the facility's policy requiring monthly weights and reweighs for significant changes, the Registered Dietitian did not review the records or request reweighs for these residents.
The facility failed to accurately assess and monitor a resident's sacral wound, leading to its progression to an unstageable stage with undermining. Despite being identified as high risk for pressure sores, the wound was inconsistently documented and miscommunicated to the physician, resulting in inadequate treatment.
A resident with a physician's order for Gabapentin 300mg for neuropathy did not receive the medication for four days due to a delay in delivery from the pharmacy. This resulted in the resident missing four doses, as confirmed by clinical and pharmacy record reviews and an interview with the DON.
Delayed Urinalysis Collection
Penalty
Summary
The facility failed to obtain laboratory services timely for one resident who was noted with increased weakness. On March 13, 2026, staff spoke with the NP and received new orders for a urine C&S, and the physician's orders also included a UA C&S. A later progress note dated March 24, 2026, documented that the resident's guardian was concerned about the resident's health status and possible change in condition, and the NP again ordered a urinalysis to be completed on March 25, 2026. The NP then documented on March 25, 2026, that nursing reported the urine ordered earlier had not yet been collected, so the NP reordered the urine; the assessment and plan noted the urinalysis was positive for gram negative rods and Macrobid was ordered. The NHA confirmed in interview that the urinalysis was not obtained when ordered on March 13, 2026, and was not obtained until March 25, 2026.
Delayed Chest X-Ray for Resident With Increased Weakness
Penalty
Summary
The facility failed to ensure that an x-ray was obtained in a timely manner for one resident who was noted to have increased weakness. On March 13, 2026, staff spoke with the nurse practitioner about the resident’s condition and received an order for a chest x-ray, but the x-ray was not obtained at that time. Later, on March 24, 2026, the resident’s guardian expressed concern about the resident’s health status and possible change in condition, and the nurse practitioner again ordered a chest x-ray to be completed on March 25, 2026. The Nursing Home Administrator confirmed in interview that the chest x-ray ordered on March 13, 2026, was not obtained until March 25, 2026.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to include residents or their responsible parties in the comprehensive care planning process for three out of five sampled residents. For Resident 1, an annual Minimum Data Set (MDS) assessment was completed on January 27, 2025, but there was no evidence that the resident or their responsible party was invited to the care plan meeting. Similarly, for Resident 2, a quarterly MDS was completed on January 7, 2025, without evidence of an invitation to the care plan meeting. Resident 3's annual MDS assessment was completed on December 9, 2024, and again, there was no documentation of an invitation to the care plan meeting. An interview with the Nursing Home Administrator confirmed the lack of documented evidence of invitations for these residents or their responsible parties to participate in their care plan meetings.
Failure to Include Interdisciplinary Team in Care Plan Meetings
Penalty
Summary
The facility failed to include the Interdisciplinary Team (IDT) in care plan meetings for 15 out of 15 resident care plan meetings reviewed. According to federal regulations, resident care plans should be prepared by an interdisciplinary team that includes the attending physician, a registered nurse, a nurse aide, a member of food and nutrition services staff, and other appropriate staff or professionals as determined by the resident's needs. However, the review of clinical records and interviews revealed that the care plan meetings lacked the required IDT participation. The care plan meetings for residents, including those with health conditions that precluded their attendance, were attended by limited staff such as social services, therapy, nursing, dietary, and respiratory staff. The absence of a comprehensive IDT, including the attending physician and other necessary professionals, was consistent across all reviewed cases. This deficiency was confirmed with the Regional Director, the Nursing Home Administrator, and the Director of Nursing.
Failure to Complete Required Annual Training
Penalty
Summary
The facility failed to ensure that four out of five reviewed staff members completed the required 12 hours of annual training. This deficiency was identified through a review of training documentation for Employees E3, E4, E5, and E6, which did not show evidence of completion of the mandated training. An interview with the Nursing Home Administrator and Director of Nursing confirmed that these employees did not fulfill the annual training requirement. This issue was previously cited on May 6, 2024, under 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to notify the physician of a significant weight change for a resident with multiple serious health conditions. The resident, who has End Stage Renal Disease (ESRD), Heart Failure, and Diabetes, experienced a notable weight gain over a short period. Specifically, the resident's weight increased from 309 pounds to 322.7 pounds within a week, and further to 330.6 pounds over the course of less than a month, totaling a 21.6-pound gain. Despite these significant changes, the clinical records did not show any notification to the physician regarding the weight fluctuations. An interview with a licensed employee confirmed that the significant weight change was identified but not communicated to the physician. This oversight represents a failure in the facility's responsibility to ensure timely physician notification of significant changes in a resident's condition, as required by regulations.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to adhere to the physician's order for fluid restriction for Resident 13, who has chronic kidney disease and hyponatremia. The physician's order specified a daily fluid restriction of 1500 ml, with specific allocations for dietary and nursing shifts. However, the clinical records did not show that Resident 13's fluid intake was monitored to ensure compliance with this restriction. Observations revealed that Resident 13 had access to more fluids than allowed, including a 16-ounce cup of water on the side table and two 16-ounce cups on the bedside table. Interviews with the resident and a licensed nurse indicated a lack of awareness and monitoring of the fluid restriction, contributing to the deficiency. For Resident 419, the facility failed to follow the physician's orders for administering Morphine Sulfate Oral Solution. The orders included specific dosages for different conditions, but the medication was incorrectly transcribed and administered. The resident received incorrect dosages, including a 20 ml dose for air hunger, which was not per the physician's order. The facility's narcotic logbook and medication incident details confirmed the administration of incorrect doses due to a transcription error. Despite the error, no adverse effects were reported for Resident 419. The deficiency was confirmed with the Nursing Home Administrator and the Director of Nursing.
Unnecessary Medication Use for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication use. Resident 21, who has a diagnosis of spinal stenosis and chronic back pain, was prescribed Oxycodone HCL 10 mg to be taken as needed for moderate pain. However, a review of the resident's Medication Administration Record for September 2024 revealed that the medication was administered 11 times despite the resident having a pain level rating of 0, indicating no pain. The clinical record did not provide an explanation for the administration of Oxycodone under these circumstances. This issue was communicated to the Director of Nursing on October 3, 2024.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on two medication carts, as observed during a survey. The facility's policy, revised in February 2023, mandates that medications and biologicals be stored in their original packaging and that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. However, during the observation of Medication Cart 4, a Lispro pen and a Basaglar pen were found used and undated, along with 97 loose medications scattered in the drawers. Similarly, Medication Cart 5 contained a Lispro pen, an Admelog pen, and a Lantus pen, each placed in a zip-lock bag with the resident's name written in pen, and 50 loose medications scattered in the drawers. Additionally, a used and undated Lidocaine vial with no name was observed. Interviews with staff revealed that the pharmacy sent multiple insulins for residents, and the original containers were left in the medication refrigerator while the insulins in use were placed in zip-lock bags. The scattered medications were attributed to accidental popping out from blister packages. These findings were communicated to the Director of Nursing, highlighting the facility's failure to adhere to its medication labeling and storage policy, as well as the manufacturer's guidelines for insulin storage.
Failure to Provide Timely Medication Administration
Penalty
Summary
The facility failed to provide necessary pain medications timely for Resident 2, resulting in significant pain and the need for emergent medical intervention. Resident 2, who was admitted with conditions including Postlaminectomy Syndrome, spinal fusion, and Cauda Equina injury, had physician orders for MS Contin, oxycodone, hydromorphone, and acetaminophen to manage chronic and breakthrough pain. However, the July 2024 Medication Administration Record (MAR) indicated that MS Contin and acetaminophen were not administered as they were on hold, and the resident experienced a pain level of 10. The medications were not delivered on time despite being faxed and refaxed by the nursing staff, and attempts to obtain them from the medication dispensing system were unsuccessful. Consequently, the resident was in severe pain and was transferred back to the hospital. Additionally, the facility failed to ensure the availability of physician-ordered medications for Resident 3, who was admitted with diagnoses including Nontraumatic Subarachnoid Hemorrhage and fractures of the lumbosacral spine and pelvis. Resident 3's orders included Donepezil, Tamsulosin, and Levetiracetam, which were not administered on a specific date due to awaiting pharmacy delivery, resulting in missed doses. The Assistant Director of Nursing confirmed that these medications were not available for administration, highlighting a lapse in the facility's pharmacy services.
Failure to Provide CPR in Accordance with Policy
Penalty
Summary
The facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of the residents reviewed. The resident, who was admitted as a short-term respite admission on hospice service, had a physician's order for full life-sustaining interventions, including CPR. However, when the resident was found unresponsive and not breathing, the RN Supervisor did not initiate CPR, citing the resident's hospice status and a conversation with the resident's daughter, who stated that the family did not wish to have CPR performed. This decision was made despite the resident's documented full code status and the facility's policy requiring CPR to be initiated unless a DNR order was in place or there were obvious signs of irreversible death. The RN Supervisor's actions were contrary to the facility's policy and the resident's physician's order, leading to the resident being pronounced dead without CPR being attempted. The facility's policy clearly stated that CPR should be initiated if the resident's DNR status is unclear, which was not followed in this case. The failure to perform CPR as required placed the resident in Immediate Jeopardy. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that they were aware of the staff's failure to provide CPR in accordance with the resident's code status and the facility's policy.
Removal Plan
- A facility wide review of all residents' life sustaining code status to ensure each resident's advanced directive and physician-ordered code status was in place.
- The facility developed an education plan for all licensed nurses regarding the facility's CPR policy including general guidelines, preparation and emergency procedure for all residents; to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders and further education on where to find the code status of residents.
- The plan also included to actively hold Code Blue drills (simulated event whereby staff respond to a resident experiencing cardiac arrest) with staff, and to complete ongoing audits.
- An audit of the eleven hospice residents including nine with Do Not Resuscitate (DNR) and Full life sustaining measures were reviewed.
- The Immediate Jeopardy was lifted when it was confirmed that the facility provided licensed nursing staff of 11 LPN's (Licensed Practical Nurses) and 4 RN's (Registered Nurses) with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR.
- Staff were able to identify resident's code status is located on the Medication Administration Record (MAR) which is accessible to all licensed staff.
- Any remaining staff were scheduled to receive the education prior to the start of their next shift.
Failure to Follow Physician's Orders for Dialysis Care
Penalty
Summary
The facility failed to follow physician's orders regarding pre-dialysis and post-dialysis weight monitoring and to maintain ongoing communication with the dialysis center for four residents receiving dialysis. Resident 18, diagnosed with End Stage Renal Disease (ESRD) and dependent on Hemodialysis, had no recorded pre and post-dialysis weights on multiple dates in April 2024. Similarly, Resident 98, also diagnosed with ESRD and dependent on Hemodialysis, had missing pre and post-dialysis weights on several dates in April 2024. Resident 161, with the same diagnosis, had multiple instances of missing pre and post-dialysis weights in April 2024. The Nursing Home Administrator confirmed the lack of documentation for these residents during an interview on April 29, 2024. Resident 369, admitted to the facility with a diagnosis of ESRD and dependence on renal dialysis, also had issues with documentation. The physician's order required a Dialysis Communication Tool to be completed and sent to dialysis three times a week, along with recording pre and post-dialysis weights. However, the Nursing Home Administrator reported that the facility did not have a communication book for Resident 369, indicating a failure to comply with the physician's orders. This lack of documentation and communication was confirmed during an interview on April 29, 2024.
Failure to Administer CPR According to Policy
Penalty
Summary
The facility failed to ensure that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with the facility policy and procedures for a resident who was a FULL CODE. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure compliance with federal and state guidelines and regulations. The job descriptions for both the NHA and DON indicated their responsibilities included ensuring proper healthcare services and providing leadership and direction for nursing services. However, they did not fulfill these essential duties, resulting in the failure to administer CPR as required by the facility's policy and procedures.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of significant weight changes in two residents diagnosed with End Stage Renal Disease (ESRD) and dependent on Hemodialysis. Resident 18 experienced a 13.8% weight gain over five days, but the clinical record did not show that the physician was notified of this significant change. Similarly, Resident 161 had a 29.78% weight gain over four days, and the physician was not notified until six weeks later. This delay in communication was confirmed by the Director of Nursing during an interview. The clinical records review and staff interviews revealed that the facility did not adhere to the requirement of promptly informing the physician about significant weight changes. This deficiency was identified through the review of the residents' weights and vitals, which showed substantial weight gains that were not communicated to the physicians in a timely manner. The Director of Nursing confirmed these findings, indicating a lapse in the facility's management and nursing services.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to comprehensively investigate an injury of unknown origin for a resident diagnosed with Dementia, Cancer of the Larynx, Acute Respiratory Failure, and generalized muscle weakness. The resident, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers, experienced worsening bilateral hip pain. An X-ray revealed bilateral subcapital fractures of undetermined age, leading to the resident's transfer to the hospital. Despite the resident denying any trauma or falls, the facility did not conduct interviews or obtain statements from staff who had cared for the resident in the last 48 hours. An interview with a licensed employee confirmed that staff interviews should have been completed for injuries of unknown origin. The Nursing Home Administrator also confirmed the lack of staff interviews or statements regarding the resident's bilateral hip fracture. This failure to ensure a comprehensive investigation of the injury constitutes a deficiency in the facility's management and nursing services.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of a resident's transfer or discharge. Specifically, a nursing progress note indicated that a resident was sent to the hospital due to being unresponsive. However, there was no documented evidence that the State Ombudsman's office was notified of this transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Develop Comprehensive Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 95, who has a diagnosis of Dementia, Bipolar Disorder, and Anxiety Disorder. The resident's Quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. Psychiatry notes revealed a history of at least four prior psychiatric hospitalizations and previous attempts to hurt self, with the resident currently on medication management. Despite this, the care plan for Resident 95 did not include any plan of care for the resident's behavior related to previous attempts to hurt self. This deficiency was confirmed during an interview with the Nursing Home Director.
Failure to Consistently Complete Wound Treatment and Follow Wound Consultant Recommendations
Penalty
Summary
The facility failed to ensure that wound treatment for Resident 18 was consistently completed and that the wound recommendation from a wound consultant was followed. Resident 18 was readmitted to the facility with a surgical wound post incision and drainage of a hematoma to the left lateral leg. A wound treatment order was given to cleanse the wound with cleanser, apply Collagen to the base of the wound, and cover with dressing daily and as needed. However, the Treatment Administration Record for April 2024 revealed that the wound treatment was not performed on April 7, 14, 16, 20, and 21, 2024. Additionally, on April 18, 2024, the wound NP evaluated Resident 18's surgical wound and recommended a new treatment involving the application of Medihoney. This recommendation was not placed as an order and therefore was not implemented. The Director of Nursing reported that the wound NP's recommendation should have been relayed to the physician for approval, but there was no documented evidence that this was done. The DON was unable to provide an explanation for the missed treatments or the failure to implement the new wound treatment recommendation.
Failure to Reduce Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free of unnecessary psychotropic medication. Resident 42 had a physician's order for trazodone 50 mg at bedtime, which was questioned by the consultant pharmacist. The psychiatrist recommended tapering off the trazodone due to its ineffectiveness and the resident being on three antidepressants. Despite this recommendation, the resident continued to receive the full dose of trazodone until March 28, 2024, leading to increased daytime sleepiness and low energy levels, as documented in the resident's progress notes and medication administration records. The Director of Nursing confirmed that the facility did not follow the psychiatrist's recommendations to reduce the trazodone dose in a timely manner. This oversight resulted in the resident experiencing excessive sleepiness and reduced food intake, as noted in a nurse's progress note. The facility's failure to act on the psychiatrist's recommendations and the pharmacist's query led to the resident continuing on an unnecessary psychotropic medication for an extended period.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to obtain and monitor weights for two residents, leading to significant unaddressed weight changes. According to the facility's Weight Policy, residents should be weighed monthly, and any significant weight change (greater than or equal to 5% gain/loss in one month) should be reported to the Registered Dietitian and reweighed. Resident 3 experienced a weight loss of 34.7 pounds (15.3%) in one month and 38.9 pounds (17.1%) over three months without a reweigh. Similarly, Resident 4 lost 16.9 pounds (10.1%) in one month without a reweigh. There was no evidence that the Registered Dietitian reviewed the records of these residents despite the significant weight losses. An interview with the Registered Dietitian confirmed that monthly weights should be obtained by the 9th of the month and reweighs should be requested for significant changes. The Registered Dietitian acknowledged that reweighs should have been obtained for both residents. This failure to follow the facility's Weight Policy and ensure proper monitoring and intervention for significant weight changes resulted in a deficiency under 483.25 F692 Nutrition/Hydration Status Maintenance.
Failure to Accurately Assess and Monitor Sacral Wound
Penalty
Summary
The facility failed to accurately assess and monitor a sacral wound for a resident, leading to the wound progressing to an unstageable stage with undermining. Initially, the resident was admitted with intact skin and was identified as high risk for developing pressure sores. Despite this, the facility's staff did not consistently and accurately document the wound's condition. The wound was initially identified as MASD and later assessed as a Stage 2 pressure ulcer, but subsequent assessments revealed it was actually a Stage 3 wound with significant slough and eschar, and eventually became unstageable with undermining. The wound care nurse and other licensed nurses provided conflicting assessments, with some documenting the wound as MASD even after it had been identified as a Stage 3 pressure ulcer. The wound care nurse confirmed that the wound was a Stage 3 on December 1, 2023, but the physician was incorrectly informed that it was a Stage 2. This miscommunication led to inappropriate treatment being continued. The wound continued to worsen, and by December 15, 2023, it was documented as unstageable with significant slough and eschar, and undermining. Interviews with the Director of Nursing and the wound care nurse revealed that the facility's protocol for wound assessment and treatment was not followed accurately. The failure to properly assess and document the wound's condition, and to communicate the correct stage to the physician, resulted in inadequate treatment and the progression of the wound to a more severe stage. This deficiency was confirmed through clinical record reviews, staff interviews, and the facility's own policy review.
Failure to Ensure Timely Availability of Medication
Penalty
Summary
The facility failed to ensure medications were available for Resident CL1, who had a physician's order for Gabapentin 300mg to be administered orally at bedtime for neuropathy. The order was dated January 26, 2024, but the medication was not administered until January 31, 2024, resulting in the resident missing four doses. The delay was due to the pharmacy not delivering the medication until January 31, 2024. This was confirmed through clinical record review, pharmacy record review, and an interview with the Director of Nursing on February 28, 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,120 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Barclay Friends | 1.6 mi | ★★★★★ | 0 | 0 |
| Park Lane Post Acute Llc | 2.5 mi | ★★★★★ | 5 | 0 |
| Pocopson Home | 4.1 mi | ★★★★★ | 0 | 0 |
| Aventura At Pembrooke | 4.3 mi | ★★★★★ | 18 | 1 |
| Crosslands | 4.7 mi | ★★★★★ | 2 | 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.