West Chester Assisted Living & Memory Care

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure food items were labeled and dated with an expiration date. This had the potential to affect all residents in the facility. The facility also failed to ensure the proper serving size was used. This affected one (#165) resident out of five residents observed for serving size. The facility also had a plethora of gnats in the kitchen. This had the potential to affect all residents. The facility census was 83.

Findings include:

1. Observation on 10/08/25 at 10:20 A.M. of the facility kitchen revealed the dry storage had opened, undated, and unlabeled rotini pasta noodles and elbow macaroni pasta noodles. There was also a plastic scoop in the sugar bin and the flour bin. The microwave had a built of grime and debris. On the prep station there was unsweetened tea with the expiration date of 10/06/25. In the prep station freezer there was opened, undated, and unlabeled waffle fries, onion rings, sweet potato fries, potato wedges, shredded hashbrowns, chicken wings, popcorn shrimp, fried okra, broccoli, chicken breast, tator tots, fish, diced chicken, garlic bread, sausage, tortellini, and tilapia.

Interview on 10/08/25 at 10:35 A.M., with the Dietary Chef #66 verified the dry storage had opened, undated, and unlabeled rotini pasta noodles and elbow macaroni pasta noodles. There was also a plastic scoop in the sugar bin and the flour bin. The microwave had a built of grime and debris. On the prep station there was unsweetened tea with the expiration date of 10/06/25. In the prep station freezer there was opened, undated, and unlabeled waffle fries, onion rings, sweet potato fries, potato wedges, shredded hashbrowns, chicken wings, popcorn shrimp, fried okra, broccoli, chicken breast, tator tots, fish, diced chicken, garlic bread, sausage, tortellini, and tilapia.

Review of the facility policy titled SG Food Labeling and Dating dated 10/13/2017 revealed all food should be labeled and dated.

2. Record review for Resident #165 revealed this resident was admitted to the facility on 11/25/1938 with the following diagnoses: diabetes, Parkinson's, and vitamin b deficiency.

Review of the Main Evaluation dated 06/09/25 revealed this resident had moderate intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 8. This resident was assessed to be independent for mobility, Resident was independent for A.M. and P.M. routine, Resident was independent for bathing, Resident was independent for toileting, and independent for dining.

Review of the physician orders revealed Resident #165 was on a pureed diet with thin liquids.

Observation on 10/08/25 at 11:30 A.M., of a kitchen pureed diet revealed the facility prepared two times the recommended serving size for Resident #165. The facility prepared eight ounces of pork chop, eight ounces of coleslaw, and four ounces of corn. The facility served eight ounces of pork chop, eight ounces of coleslaw, and four ounces of corn.

Interview on 10/08/25 at 11:30 A.M., with the Dietary Chef #66 verified the facility prepared and served eight ounces of pork chop, eight ounces of coleslaw, and four ounces of corn for Resident #65. The Dietary Chef #66 verified the facility should of prepared four ounces of pork chop, four ounces of coleslaw, and four ounces of corn.

3. Observation on 10/08/25 at 11:40 A.M., of the kitchen revealed there was a plethora of gnats in the kitchen near the dry storage, the freezer, and the kitchen prep station.

Interview on 10/08/25 at 11:42 A.M., with the Dietary Chef #66 verified there was a plethora of gnats in the kitchen near the dry storage, the freezer, and the kitchen prep station.

This violation represents non-compliance investigated under Complaint Number OH00168006.

Based on review of the self-reported incident, record review, staff interview, and facility policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed at risk for elopement did not elope from the facility. This affected one (#45) of three residents reviewed for elopement. In addition, the facility failed to ensure the dryer lint traps were free of lint. This had the potential to affect all residents who reside in the facility. The facility census was 83.

Findings Include:

1. Record review revealed Resident #45 was admitted to the facility on 12/20/25 with the following diagnoses: depression with behavior disturbance, dementia, and paranoia.

Review of the most recent service plan dated 10/03/25 revealed Resident #45 had severe cognition impairment evidenced by a Brief Interview for Mental Status (BIMS) score of seven. The resident was assessed to be an elopement risk and was identified to wander with exit seeking behavior. The resident was assessed as independent for mobility, required reminders for routine assistance, standby assist for bathing, independent for toileting, and set up assistance for meals. The resident was continent of bowel and bladder.

Review of the self-reported incident (SRI) number 258976 dated 10/09/25 at 3:40 P.M. revealed Resident #45 had an elopement on 04/02/25 at approximately 3:43 P.M. On 04/02/25 at approximately 3:43 P.M. Housekeeper #202 went to leave the facility and saw Resident #45 with their keys and purse. Housekeeper #202 let Resident #45 exit due to thinking Resident #45 was a visitor instead of a Resident. In the middle of head count the facility was notified by the dental office 900 feet away from the facility that the Resident was found inside their office. The facility substantiated neglect. At 3:56 P.M., the facility was notified Resident #45 was sitting in the lobby of the dental office looking for her car. She was brought back to the facility and assessed without injuries. Per the SRI the facility began education, assessed all residents, and completed random elopement drills.

Interview on 10/14/25 at 10:30 A.M., with the Regional Nurse Consultant #202 verified Resident #45 had an elopement on 04/02/25 at approximately 3:43 P.M. On 04/02/25 at approximately 3:43 P.M. Housekeeper #202 went to leave the facility and saw Resident #45 with their keys and purse. Housekeeper #202 let Resident #45 exit due to thinking Resident #45 was a visitor instead of a Resident. In the middle of head count the facility was notified by the dental office 900 feet away from the facility that the Resident was found inside their office. The Regional Consultant #202 said the housekeeper should not have let Resident #45 out of the memory care unit and should have found an aide or a nurse to identify this was indeed a visitor.

Facility policy titled Elopement/Missing Resident OH Region dated on 06/06/24 revealed the facility should maintain safety of all residents by preventing elopements.

2. Observation on 10/08/25 at 10:00 A.M., with Wellness Director revealed in the assisted living main laundry room there was approximately two inches of lint buildup in the commercial dryer.

Interview on 10/08/25 at 10:02 A.M., with Wellness Director verified there was approximately two inches of lint buildup in the commercial dryer.

This violation represents non-compliance investigated under Control Number OH00164554.

Based on record review and staff interview, the facility failed to ensure activities of daily living were carried out by staff. This affected four (#424, #426, #360, and #390) out of eight residents reviewed for activities of daily living. The facility census was 83.

1. Record review revealed Resident #424 was admitted to the facility on 05/09/2025 with the following diagnoses: unspecified atrial fibrillation, non-toxic multinodular goiter, and recurrent depressive disorder.

Review of the main evaluation assessment dated 05/09/25 revealed Resident #424 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13-15 and was independent for mobility, standby assist for bathing, and independent for toileting.

Review of the assistance documentation for Resident #424 revealed in May 2025 A.M. assistance was completed 14 out of 19 days scheduled and P.M. assistance was completed two out of 19 days. During June 2025 A.M. assistance was completed 13 days out of 30 days and P.M. assistance was completed eight days out of 30 days that were scheduled for care. Bathroom assistance for the A.M. shift was completed nine out of 18 times and the P.M. shift was completed three out of 20 times scheduled.

2. Record review for Resident #426 revealed this resident was admitted to the facility on 05/05/25 and discharged on 07/07/25 with the following diagnoses: Alzheimer's disease and essential hypertension.

Review of the main evaluation 06/16/25 revealed Resident #426 had severe cognition impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 0. This resident was assessed to require assistance with A.M. and P.M., routine care, which required physical assistance for showers one to two times a week, complete bathroom assistance, and physical assistance with feeding and eating.

Review of the assistance documentation for Resident #424 revealed in June 2025 A.M. assistance was completed 13 days out of the 30 scheduled days and P.M. routine assistance was completed eight days out of 30 scheduled days. Bathroom assistance for the A.M. during June 2025 was completed nine out of 19 scheduled days and P.M. bathroom assistance was completed four out of 20 days.

3. Record review for Resident #360 revealed this resident was admitted to the facility on 12/10/24 with the following diagnoses: Dementia and Hypertension.

Review of the main evaluation dated 06/16/25 revealed Resident #360 had severe cognition impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 0. The resident required standby assistance for bathing, required A.M., and P.M. assistance.

Review of the assistance documentation for Resident #360 revealed in August 2025 A.M. assistance was completed 29 out of 31 scheduled times. In September 2025 A.M. assistance was completed 25 out of 30 scheduled times and P.M. assistance was completed 21 out of 30 times. Incontinence assistance in September 2025 was completed 25 out of 30 times during first shift and 21 out of 30 times during third shift. In October 2025 A.M. assistance was completed five out of eight times, P.M. assistance was completed six out of eight times, and incontinence assistance occurred five out of eight times during first shift.

4. Record review for Resident #390 revealed the resident was admitted to the facility on 12/13/24 with the following diagnoses: Alzheimer's disease, hypertension, and memory loss.

Review of the main evaluation dated 10/13/25 revealed Resident #390 had severe cognition impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 0-7. The resident required complete bathroom assistance, shower assistance, and A.M. / P.M. assistance.

Review of the assistance documentation for Resident #390 revealed in October 2025 A.M. care was provided five out eight times and P.M. care was provided seven out of eight times. Incontinence care was provided four out of eight times during first shift and seven out of eight times during second shift. Toileting assistance was provided three out of eight times during first shift and seven out of eight times during second shift.

In September 2025 A.M. care was provided 22 times out 30 and P.M. care was provided 21 out of 30 times. Bathing Assistance was provided five out of eight times. Incontinence care was provided 20 out of 30 times during first shift and 20 out of 30 times during second shift.

In August 2025 A.M. care was provided 25 out of 31 times and P.M. care was provided 30 out of 31 times. Incontinence care was provided 24 out of 31 times during first shift and 30 out of 31 times during second shift.

Interview on 10/14/25 at 11:45 A.M., with the Regional Nurse Consultant #202 verified the above documented lack of care findings for Resident #360, #424, #390, and #426.

This violation represents non-compliance investigated under Complaint Number OH00168308, OH00168292, OH00166790, OH00162383, and OH00161462.

Based on record review and staff interview the facility failed to ensure the evacuation of capable residents during fire drills were conducted. This had the potential to affect all 46 residents residing in the facility. The census was 46.

Findings include:

Review of the facilities fire drills for the past 12 months revealed no evidence of any resident evacuation during fire drills.

Interview was conducted on 08/19/24 at 3:00 P.M. with the Administrator and verified the facility was not evacuating any residents that were capable of evacuation during any of the fire drills.

Based on record review and staff interview, the facility failed to ensure Resident Assistants (RA) had evidence of adequate training prior to providing personal care services. This affected three (RA #14, RA #56, and RA #72) out of three RA personnel files reviewed for staff training. This had the potential to affect all 45 residents residing in the facility.

Findings include:

Review of the personnel files for RA #14, RA #56, and RA #72 revealed all three were hired on 05/31/24 and there was no evidence of completed skills checklists.

Interview on 07/30/24 at 11:43 A.M. with Corporate Nurse (CN) #80 confirmed no evidence of completed skills checklists for RA #14, RA #56, and RA #72.

This was an incidental finding discovered during the course of the complaint investigation.

Based on record review and staff interview, the facility failed to ensure residents received appropriate care and services during transfers to prevent falls. This affected one (#21) resident of three residents reviewed for transfers and falls. The facility census was 45.

Findings include:

Review of the medical record for Resident #21 revealed an admission date of 12/09/21. Diagnoses included coronary artery disease, pulmonary fibrosis, chronic obstructive pulmonary disease, osteoarthritis, low back pain, weakness, wedge compression fraction of the fourth lumbar vertebrae, and spinal stenosis.

Review of the functional assessment dated 05/31/24 revealed Resident #21 was oriented to person, place, and time.

Review of the service plan dated 05/31/24 revealed Resident #21 used a manual wheelchair and required assistance with transfers.

Review of the incident report dated 06/21/24 revealed the nurse was called to Resident #21's room by the Resident Assistant (RA). The nurse observed Resident #21 on the floor in front of his wheelchair. The nurse asked Resident #21's wife what happened, and Resident #21's wife stated the wheelchair was not locked when the RA tried to transfer Resident #21 from a chair to his wheelchair. The incident report indicated Resident #21 had skin breakdown on his right hand that was bleeding and complained of head pain. Resident #21 was noted to be alert and oriented and was sent to the emergency room. The nurse notified Resident #21's emergency contact and primary care physician.

Interview on 07/30/24 at 3:40 P.M. with Corporate Nurse (CN) #80 confirmed Resident #21's fall occurred due to an improper transfer.

Interview on 07/30/24 at 4:25 P.M. with RA #56 stated she went to Resident #21's room to answer the call light. RA #56 reported Resident #21 indicated he was ready for bed, and she started to assist him. RA #56 confirmed the wheelchair brakes were unlocked, and that Resident #21 fell on his right side and hit his head.

This violation represents non-compliance investigated under Complaint Number OH00155421.

Based on record review and staff interview, the facility failed to ensure a notation was made in the resident's record regarding a resident's fall. This affected one (#21) of three residents reviewed for falls. The facility census was 45.

Findings include:

Review of the medical record for Resident #21 revealed an admission date of 12/09/21. Diagnoses included chronic obstructive pulmonary disease, osteoarthritis, low back pain, chronic kidney disease stage two, weakness, wedge compression fraction of the fourth lumbar vertebrae, and spinal stenosis.

Review of the functional assessment dated 05/31/24 revealed Resident #21 was oriented to person, place, and time.

Review of the service plan dated 05/31/24 revealed Resident #21 used a manual wheelchair and required assistance with transfers.

Review of the incident report dated 06/21/24 revealed the nurse was called to Resident #21's room by the Resident Assistant (RA). The nurse observed Resident #21 on the floor in front of his wheelchair. The nurse asked Resident #21's wife what happened, and Resident #21's wife stated the wheelchair was not locked when the RA tried to transfer Resident #21 from a chair to his wheelchair. The incident report indicated Resident #21 had skin breakdown on his right hand that was bleeding and complained of head pain. Resident #21 was noted to be alert and oriented and was sent to the emergency room. The nurse notified Resident #21's emergency contact and primary care physician.

Review of the progress notes from 06/21/24 to 07/30/24 revealed no evidence of documentation, such as injuries or what contributed to the fall was noted in Resident #21's medical record.

Interview on 07/30/24 at 3:40 P.M. with Corporate Nurse (CN) #80 confirmed Resident #21's medical record lacked a notation regarding what caused the fall, or any injuries Resident #21 sustained.

This was an incidental finding discovered during the course of the complaint investigation.