Health inspection·February 29, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interviews, it was determined that the facility failed to ensure injury of unknown cause was comprehensively investigated for one two residents reviewed (Resident 1) Residents Affected - Few Findings include: Review of clinical records of Resident 1 revealed Resident 1 was admitted to the facility on [DATE], with diagnosis of Dementia (A term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), and fracture of the left femur (thigh bone). Review of Resident 1's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 21, 2023, revealed resident had severe cognitive impairment and required dependent assistance with transferring. Review of facility documentations and clinical records revealed Resident 1 had an unwitnessed fall on December 22, 2023, at 7:18 p.m., and December 24, 2023, at 5:32 p.m. Resident was assessed with no injury observed on both falls. Review of the nursing progress notes dated December 29, 2023, at 6:46 p.m., revealed that the daughter in law requested for an x-ray of the foot because the resident complained of a pain when foot was massaged. An x-ray of the left ankle and foot was ordered. The x-ray result was Acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The resident was medicated with round the clock Tylenol (pain medication). Review of the facility documentation and clinical records failed to reveal that the identified fracture on Resident 1's left foot was investigated. Interview conducted with the Nursing Home Administrator on February 28, 2024, at 1:00 p.m., revealed that left foot fracture identified on December 29, 2023, was not investigated because staff believed the fracture was present from the hospital due to family's report of pain in the hospital and resident saying ouch when left foot was touched. The facility was unable to provide a documentation indicating left foot fracture occurred prior to admission to the facility. The facility failed to investigate Resident 1's left foot fracture of unknown origin. 28 Pa. Code: 211.12(d)(1)(5) Nursing services (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 4 Event ID: 395595 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 395595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013 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)