Deficiency Records for West Chester Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for West Chester Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-05 | 2023-09-05 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-16 | 2023-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-16 | 2023-07-17 | N |
| 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 | 2023-06-16 | 2023-07-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-16 | 2023-07-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-16 | 2023-07-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-16 | 2023-07-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-16 | 2023-07-17 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-06-16 | 2023-07-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-07-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-16 | 2023-06-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-07 | 2023-03-29 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-28 | 2022-08-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-28 | 2022-08-23 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-06-28 | 2022-08-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-28 | 2022-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-17 | 2022-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-08-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-17 | 2022-08-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-17 | 2022-08-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-17 | 2022-08-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-17 | 2022-08-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-17 | 2022-08-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-03-31 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-03 | 2022-03-31 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-01-11 | 2022-01-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-11 | 2022-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-30 | 2021-11-29 | 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 | 2021-10-04 | 2021-11-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-09-20 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-06-10 | 2021-08-02 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-10 | 2021-08-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-06 | 2021-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-06 | 2021-06-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-06 | 2021-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-06 | 2021-06-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-06 | 2021-06-16 | 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 | 2021-05-06 | 2021-06-16 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-06 | 2021-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-06 | 2021-06-16 | Y |
