F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon
clinical record review and staff interview, it was determined the facility failed to ensure accurate Minimum
Data Set Assessments were completed for one of 12 residents reviewed (Resident 14).
Residents Affected - Few
Findings include:
Review of Resident 14's clinical record revealed diagnoses including End Stage Renal Disease (failure of
kidney function to remove toxins from the blood).
Review of Resident 14's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs)
dated Mach 17, 2025 failed to reveal Resident 14's diagnosis of End Stage Renal Disease.
Interview with Licensed Employee E3 on June 12, 2025, at 11:43 a.m. confirmed Resident 14's Quarterly
MDS dated [DATE], was inaccurately completed.
28 Pa. Code 211.5(f) Clinical Records
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 3
Event ID:
396090
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
396090
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Preston Residence
200 Sycamore Drive
West Grove, PA 19390
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of clinical records and staff interviews, it was determined the facility failed to ensure that
fluid restriction physician's orders were followed for one of one residents reviewed. (Resident 10)
Residents Affected - Few
Findings include:
A review of the facility's policy titled Diets and Menus, Subject: Fluid Restrictions revised 5/2023 revealed
Nursing will document fluid restrictions, intake and output as per nursing policy and procedures or as per
physician orders.
Review of Resident 10's clinical record revealed diagnoses including acute congestive heart failure(sudden
and severe condition where the heart can't pump enough blood to meet the body's needs, causing fluid
buildup in the lungs and other parts of the body), and acute kidney failure (a sudden and significant loss of
kidney function).
Review of Resident 10's physician's orders revealed an order started on May 26, 2025, of fluid restriction of
2000cc, Split between Nursing (1000cc) and Dining (1000cc) daily. 7-3:450cc, 3-11:450cc,11-7:100cc.
Review of Resident 10's Medication Administration Record revealed Resident 10's daily fluid allotment was
not recorded from June 1, 2025, to June 10 2025.
Interview with Director of Nursing on June 12, 2025, at approximately 12:24pm confirmed that the physician
orders were not followed for fluid restriction.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396090
If continuation sheet
Page 2 of 3
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
396090
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Preston Residence
200 Sycamore Drive
West Grove, PA 19390
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based upon clinical record review and interview, it was determined the facility failed to ensure
non-pharmaceutical interventions were completed prior to the administration of pain medication for one
resident and failed to ensure side effects were being monitored during the use of anti-psychotic medication
for one resident (Resident 4 and Resident 11).
Residents Affected - Few
Findings include:
Review of Resident 4's physician orders revealed an order for Oxycodone (pain medication) 10 milligrams
(mg) to be administered every eight hours as needed for moderate to severe pain.
Review of Resident 4's June Medication Administration Record revealed Resident 4 received Oxycodone
10 mg on June 1, 2025, June 2, 2025, June 3, 2025, June 6, 2025, and June 10, 2025.
Further review of Resident 4's clinical record failed to reveal evidence that non-pharmaceutical
interventions were attempted prior to the administration of Oxycodone 10 mg.
Interview with the Director of Nursing on June 12, 2025, at 1:00 p.m. confirmed that non-pharmaceutical
interventions were not attempted prior to the administration of Resident 4's pain medication.
Review of Resident 11's diagnosis list revealed a diagnosis of Alzheimer's Dementia (a progressive disease
that destroys memory and other important mental functions), unspecified mood disorders and anxiety
disorder.
Review of Resident 11' s physician's orders revealed an order started on Decemebr 5, 2024 for Quetiapine
(anti-psychotic medication) 25 milligrams 1 tablet at bedtime.
Review of Resident 11's Medication Administration Record (MAR) for May 2025 and June 2025 revealed
Resident 11 received Quetiapine 25 milligrams each day at bedtime.
Review of Resident 11's MAR and progress notes revealed the facility failed to ensure that side effects
were being monitored during the use of anti-psychotic medication.
Interview with the Director of Nursing on June 13, 2025, at 9:18 a.m. confirmed there was no
documentation monitoring the side effects of the anti-psychotic medication when administered to Resident
11.
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 7/11/2024
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396090
If continuation sheet
Page 3 of 3
