Health inspection·January 17, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to ensure the call bell alerts were answered in a timely manner on one of two floors. (First Floor) Residents Affected - Few Findings include: Observation conducted on January 17, 2024, at approximately 12:15 p.m., of the call bell alert unit at the first-floor nursing station, responsible for monitoring room [ROOM NUMBER], revealed that the room's call bell was on for 17 minutes. Continued observation on January 17, 2023, from 12:15 p.m. through 1:00 p.m. revealed the call bell alert system continued to be activated for room [ROOM NUMBER]. Interview conducted on January 17, 2024, at approximately 1 p.m., with Resident R2, revealed that he/she pushed the call bell for staff assistance. R2 confirmed the call bell remained activated at time of the interview. R2 could not confirm the exact time call bell was initiated but stated it had been a while. R2 stated his/her bed was broken and was the reason he/she pushed the call bell for assistance. R2 stated that he/she informed staff the previous day and earlier that morning the bed was broken. Additional observation conducted on January 17, 2024, at 2:31 p.m., revealed the call bell alert system was activated by lights inside the room and outside of the door and appeared to be operating properly. Further observation of staff responded to a call bell alert within three minutes of activation, indicating the system was working properly at the nurse's station as well. Additional observation conducted on January 17, 2024 revealed maintenance personnel taking a new bed towards R2's room. Interview conducted on January 17, 2024, at approximately 3:35 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that they interviewed R2 and roommate R3 concerning the call bell alert system in their room. NHA and DON stated both residents denied activating the call alert system at anytime during the day. NHA and DON provided a signed statement from both R2 and R3 documenting neither activated the system. NHA and DON stated that nursing staff did go into the resident's room to provide medications during the time of observation. Further interview with Administrator and Director of Nursing revealed in response to enquiry of Page 1 of 3 395740 395740 01/17/2024 West Chester Rehabilitation and Healthcare Center 800 West Miner Street West Chester, PA 19382

F 0558 reason the call bell system would remain activated at the nurse's station, the NHA and DON replied that the system was new and not fully operational. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of Licensee Residents Affected - Few 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395740 Page 2 of 3 395740 01/17/2024 West Chester Rehabilitation and Healthcare Center 800 West Miner Street West Chester, PA 19382

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to implement the comprehensive care plan interventions to prevent pressure ulcer healing and discomfort for one of three resident reviewed (Resident R1). Findings include: Review of R1's records revealed a care plan dated December 24, 2023, documenting the resident has a pressure ulcer or has potential for pressure ulcer development related to disease process, immobility, sacral wound. Interventions documented the need for staff to elevate/offload heels when in bed as tolerated using pillows, bootie, heel protectors or heel cushions. Observation of R1 on January 17, 2024, at 12:30 p.m., revealed the resident lying in bed with resident's heels contacting a pillow. Observations also revealed resident wearing socks, with no heel booties, heel protectors or heel cushions. Further observation of resident's room revealed heel booties sitting on air conditioner unit. Interview on January 17, 2024, at 12:35 p.m., with E3 revealed that R1 often refused to wear the heel booties because they were painful. Observation of R1 on January 17, 2024, at 1:50 p.m., revealed that staff had put the heel booties on the resident, although it was known to staff that the resident did not like to wear them because they were painful. Interview with the resident confirmed they were painful, and the resident did not want to wear them. Interview conducted on January 17, 2024, at approximately 3:30 p.m., with Nursing Home Administrator and Director of nursing, confirmed Resident R1 was care planned for pressure ulcers with interventions to include elevate/offload heels when in bed as tolerated using pillows, heel booties, heel protectors or heel cushions but the interventions were not implemented, as noted by observation. The facility failed to implement Resident R1's comprehensive care plan which included interventions to offload heels to prevent pressure wounds. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 395740 Page 3 of 3