Exton Post Acute

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in freezer were properly stored and labeled to prevent contamination and ensure safe storage in accordance with professional standards for food service safety in one of one kitchen areas. (Main Kitchen)

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to develop a care plant for residents on Dialysis (A process of purifying the blood of a person whose kidneys are not working normally) in a timely manner for two of three residents reviewed (Resident 1 and 38).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one out of six residents reviewed (Resident 115). Findings Include:Review of facility policy for Care Plans, Comprehensive Person-Centered, revised March 2022, revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. [...]

Inspectors wroteBased on a review of the facility's policy, clinical records review and resident and staff interviews, it was determined the facility failed to ensure physicians' orders were followed for two of 21 residents reviewed (Residents 1 and 38).

Inspectors wroteBased on observation, clinical records review, and resident and staff interview, it was determined the facility failed to follow the physician's order for PICC (a peripherally inserted central catheter with two lines that allows the provider to deliver more than one therapy directly into the blood stream) line care by not changing the PICC dressing within 7 days for one of two residents reviewed (Resident 26).

Inspectors wroteBased on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for two of three dialysis residents reviewed. (Residents 31 and Resident 38).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to respond to recommendations made by the consultant pharmacist during monthly medication reviewed for three of five residents reviewed. (Residents 3, 1, and 115)

Inspectors wroteBased on review of facility policy, resident's clinical records, staff interviews, and observations, it was determined the facility failed to follow transmission-based precautions for one of 24 residents reviewed. (Resident 12)Findings Include:Review of facility policy Clostridioides (Clostridium) Difficile (a bacterium causing diarrhea), last revised December 2024, states, Residents with diarrhea and suspected CDI (Clostridium Difficile infection) are placed on contact precautions (measure of infection control requiring gloves and gown to be worn during patient care, as well as hand washing with soap and water) while awaiting laboratory results. Review of Resident 12's Nurse Practitioner Notes revealed that on April 6, 2026, at 9:30 a.m., the resident complained of having multiple liquid stools and an order was placed to collect a stool sample to rule out Clostridium Difficile. [...]

Inspectors wroteBased on review of guidelines for Cardiopulmonary Resuscitation (CPR), facility's policies, staff interviews and residents' clinical and hospital records, it was determined the facility failed to ensure that code status was documented on the residents clinical record delaying the decision to provide life sustaining measures such as CPR for one of five residents reviewed (Resident CL1), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform life sustaining interventions.

Inspectors wroteBased on clinical review and staff interview, it was determined that the facility failed to follow a physician's recommendations for one of five residents reviewed (Resident CL2).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to follow a blood work order in a timely manner for one of five residents reviewed (Resident CL2)

Inspectors wroteBased on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that Cardiopulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code.

Inspectors wroteBased on a review of hospital and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician's order from the hospital was followed and accurately communicated to the facility's physician for one of the two residents reviewed (Resident CL1).

Inspectors wroteBased on a review of facility policy, review of personnel files and interviews with staff, it was determined that the facility failed to implement their policy to screen employees according to the Older Adults Protective Services Act for one of five employees (Employee E3).

Inspectors wroteBased on review of clinical records, incident reports, policy review, and staff interviews it was determined the facility failed to ensure that one of 18 residents reviewed was free of a significant medication error, which compromised the resident's clinical condition and resulted in actual harm when the resident required a hospital admission. This is being cited as past noncompliance. (Resident R1) Findings Include: Review of facility policy titled, Reconciliation of Medications on Admission undated, revealed, the purpose of the procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Review of facility policy titled Administering Medications undated, revealed the purpose of the policy is to ensure medications are administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to assist one of one (Resident 43) residents in making transportation arrangements to and from multiple orthopedic surgery appointments resulting in actual harm by causing a deterioration of the wound and being admitted to a hospital for wound washing, and failure to follow a medication order from the physician for one out 19 residents reviewed (Resident 30).

Inspectors wroteBased on review of clinical records, hospital records, and interviews with resident and staff, it was determined that the facility failed to provide adequate supervision and assistance, resulting in harm from a fall which led to hospitalization and further surgical procedures and treatments for one of the 19 residents reviewed (Resident 20).

Inspectors wroteBased on review of facility's policy, observations and staff interviews, it was determined the facility failed to ensure infection control was practiced for a resident with COVID and Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of MDRO-multidrug-resistant organisms in nursing homes) were in place for residents requiring enhanced barrier precautions for seven of seven residents reviewed (Resident 8, 13, 20, 21, 30, 46, and 105).

Inspectors wroteBased on review of facility's policy, clinical records and hospital record review, and interview with resident and staff, it was determined the facility failed to report a fall to the state agency for one of 19 residents reviewed (Resident 20).

Inspectors wroteBased on review of facility policy, clinical record review, hospital record review, and interviews with resident and staff, it was determined the facility failed to investigate a fall for one of 19 residents reviewed (Resident 20).

Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow the wound treatment recommended by the wound specialist in a timely manner for one of the 11 residents reviewed (Resident 28).

Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to obtain baseline weight and re-weight for significant weight change for two of the 19 residents reviewed (Resident 28 and 105).

Inspectors wroteBased upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, (E8, E9, E10, E11, E12).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide appropriate indication and consistently attempt a non-pharmacological intervention before administering anti-anxiety medication for one of five residents reviewed (Resident 46).

Inspectors wroteBased on a review of the facility's policy, and drug manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for two of four medication carts reviewed (1 East medication cart 1 and 2).

Inspectors wroteBased on facility policy and procedure review, staff interview and resident record review it was determined the facility failed to complete skin assessments to monitor skin conditions and prevent pressure ulcers for one of six residents reviewed causing actual harm to Resident 1 when they developed a stage 3 pressure ulcer to the sacrum(Resident 1). Findings Include: Review of facility policy and procedure titled Skin Integrity and Wound Management revealed under practice standards the following Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Identify patient's skin integrity status and need or prevention or treatment interventions through review of all appropriate assessment information. [...]

Inspectors wroteBased on a clinical records review and staff interview, it was determined that the facility failed to ensure that the medications ordered by the physician were available for one of the three residents reviewed (Resident CL1).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure initial weight was accurately taken for baseline, and reweighting was timely done to address a significant weight change for one of two residents reviewed (Resident CL1).

Inspectors wroteBased on a review of the facility's policy, observations, and staff interviews, it was determined that the facility failed to ensure safe and sanitary food preparation and storage in the main kitchen.

Inspectors wroteBased on clinical record review and staff and family interviews it was determined the facility failed to provide ADL care to dependent resident for 2 of ten residents reviewed. (Residents 1 and 5) Findings Include: Interview with Resident 1's Power of Attorney on April 24, 2024 at 10:30 a.m. revealed the resident has not had a shower since admission. Review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident 1's Plan of Care response history for bathing revealed the resident was not documented as having received a shower since admission. Review of Resident 5's Clinical record revealed the resident was admitted to the facility on [DATE] and discharged on April 2, 2024. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to provide pharmacy services for one of ten residents reviewed. (Resident 2)

Inspectors wroteBased on clinical record and laboratory documentation reviews, and staff interview, it was determined that the facility failed to ensure blood work ordered by the physician was completed for one of the 22 residents reviewed (Resident 257).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to follow physician orders for podiatry consult and/or treatment for one of one residents reviewed (Resident R1).

Inspectors wroteBased on facility's policy, clinical records, facility investigation reviews; and staff interviews, it was determined that the facility failed to follow policy and procedures for hot beverages for one resident resulting in harm of a third-degree burn (injury that involves the outer layer of the skin and part of the inner layer of the skin) for one resident reviewed (Resident 1).

Inspectors wroteBased on observation, clinical records review and interview with staff, it was determined that the facility failed to ensure appropriate monitoring and treatment was provided to a newly identified Stage 2 (partial thickness loss of dermis or an intact or open/ruptured serum-filled blister) wound for one of two residents reviewed (Resident 1).