Inspection·September 5, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of facility documentation and clinical record review, it was determined that the facility failed to ensure adequate supervision during a transfer for one of four residents reviewed (Resident 1). This was identified as a past noncompliance situation. Findings include: Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) revealed under Section G - Functional Status, that the resident was totally dependent on two staff persons for transfers. Review of Resident 1's progress notes revealed a nurse's note on August 22, 2023, which stated: resident alert, at 5:50 am, resident said, when [nurse aide Employee E2] put her in her [wheelchair] while still on the Hoyer Lift, [Employee E2] try to pull her Hoyer pad up and the Hoyer tip hit her left neck. Further review of Resident 1's progress notes revealed an x-ray was obtained same day and revealed there were no injuries. Review of phone interview by the Director of Nursing (DON) with Employee E2 on August 24, 2023, revealed Employee E2 confirmed she Hoyer lifted [Resident 1] into her wheelchair without assistance/2nd person .DON inquired why a second staff member was not present during Hoyer lift transfer, employee stated she was rushing to get resident up for dialysis and did not ask anyone for help. Employee acknowledges she is competent to know she needs two people for all mechanical lift transfers. Employee E2 received disciplinary action as a result of the incident. Interviews conducted throughout the day of the survey with Licensed Nurse Employees E3 and E4, and nurse aide Employees E5, E6, E7, E8, and E9 all confirmed staff were aware that all transfers with mechanical lifts require two staff persons. Review of staff in-services revealed all staff were re-educated on needing two staff persons present while using a mechanical lift by August 29, 2023. Review of audits revealed that random audits of residents who required use of a Hoyer lift were being conducted to ensure transfers were being done appropriately with two staff persons present. Audits will continue to be completed and reviewed by the Director of Nursing. Interview with the Director of Nursing on September 5, 2023, at approximately 1:30 p.m., confirmed nurse aide Employee E2 should have had a second staff person present when transferring Resident 1 in the Hoyer lift. (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 2 Event ID: 395740 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 395740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Chester Rehabilitation and Healthcare Center 800 West Miner Street 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)