Inspection·August 15, 2024

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to ensure the pharmacy provided necessary pain medications timely which resulted in Resident 2 experiencing significant pain, and prompting emergent medical intervention. The facility failed to ensure physician ordered medications were available from the pharmacy for two of four residents reviewed (Residents 2 and 3). Findings include: Review of Resident 2's progress note of July 27, 2024, revealed resident was admitted at approximately 1:30 p.m. Review of the clinical record included diagnoses of, but not limited to, Postlaminectomy Syndrome (pain that continues after a Laminectomy [surgery that reduces pressure on the nerves in the spinal cord] or other spinal surgery, fusion of the spine (surgery to connect two or more bones in any part of the spine), lumbar region (lower back) , and injury of Cauda Equina (bundle of spinal nerves and spinal nerve rootlets). Review of Resident 2's physician's admission orders included an order for MS Contin (morphine medication used to treat moderate to severe pain) oral tablet extended release 100 milligrams (mg), one tablet two times a day for chronic pain, oxycodone HCl (opiod medication used to treat moderate to severe pain) oral tablet 30 mg two tablets every four hours as needed for breakthrough pain, and hydromorphone HCl (opiod medication used to treat moderate to severe pain) oral tablet 4 mg two tablets every eight hours as needed for severe pain if no relief from oxycodone. Additional order received to monitor resident for pain every shift. Resident 2 also had an order for Acetaminophen (pain reliever for mild to moderate pain) 325 mg two tablets every six hours as needed for pain. Review of the July 2024 Medication Administration Record (MAR) for Resident 2, revealed a pain level of 10 (scale of 0-10, 0 means no pain, 10 worst pain) recorded for nite. Further review of Resident 2's MAR revealed that MS Contin was not administered at 9:00 p.m. because it was on hold'. The MAR also indicated that Acetaminophen was not administered. Review of Resident 2's progress note of July 27, 2024, at 23:46 (11:46 p.m.) revealed Residents' routine and prn narcotics were not delivered on the last run. Scripts were faxed by day shift nurse at 1515 [3:15 p.m.] and refaxed at 1725 [5:25 p.m.] on 7/27/24. This RN (Registered Nurse) attempted to pull the medications from the pixus [pyxis - medication dispensing system] with no success. Resident is on high doses of multiple narcotics. Pixus does not have the right dose and enough dose to administer. Resident is in severe pain and requesting to go back to the hospital. [Attending Physician] made aware and is agreeable. ADON (Assistant Director of Nursing] made aware. Spouse is at bedside. Resident left the building at 2320 [11:20 p.m.] with all of his belongings. Resident went to [local (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 08/15/2024 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)