Inspection·April 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on a review of the facility's policy, observation, clinical records review, and interview with resident and staff, it was determined that the facility failed to notify the physician of a significant weight change for one of the 13 residents reviewed (Resident 79). Findings include: Review of the facility's policy titled Notification of Change In Resident Condition, with an effectivity date of April 2018, revealed that it is the facility's policy to inform the physician, resident, resident's family/legal representative anytime there is a change in resident condition or change the current plan of care. The nursing staff will notify the physician and family/legal representative of any resident if there is a change in weight or nutritional status. Review of Resident 79's diagnosis list revealed Hypertension (Elevated blood pressure), Peripheral Vascular Disease (PVD-A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and localized edema (swelling). Review of Resident 79's weights and vitals revealed a weight of 196 pounds on February 7, 2023, and 206. 6 pounds on February 14, 2023, a 10.6 pounds (5.41%) significant weight gain in one week period. Review of the Nutrition/Dietary notes dated February 21, 2023, at 11:51 a.m., revealed weekly weights obtained on February 7, 2023, was 196, and February 14, 2023, was 2023. 11 pounds gain occurred in one week, pitting (+1) edema to bilateral lower extremity noted on February 6, 2023. Diet continues as same with no change in intakes, continue to monitor weights weekly for further changes. Review of clinical records failed to reveal that the significant weight change identified on February 14, 2023, was reported to the physician. Observation and interview with Resident 79 were conducted on April 25, 2023, at 1:30 p.m. Resident was sitting on a wheelchair, resident was wearing a stocking on both legs. The resident reported that his/her legs had been swollen. Interview with the Director of Nursing (DON) was conducted on April 27, 2023, at 11:00 a.m. The DON reported that nursing notifies the physician of a significant weight change. The DON confirmed that the nurse did not notify the physician of Resident 79's significant weight change identified on February 14, 2023. The DON also confirmed that the dietitian identified and documented Resident 79's significant weight change but did not communicate it with nursing, thus physician was not notified. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395384 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pocopson Home 1695 Lenape Road West Chester, PA 19382 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)