Inspection·October 2, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to implement interventions that prevented new or worsened pressure ulcers for three of three sampled residents with skin impairments. (Residents 1, 2, 3) Residents Affected - Few Findings include: Review of a facility policy entitled, Pressure Ulcer Prevention, last reviewed September 2024, revealed that staff were to conduct a skin assessment with the weekly risk assessment. Residents at risk for pressure ulcers were to be repositioned on an individualized schedule. Clinical record review revealed that Resident 1 had diagnoses that included protein calorie malnutrition (PCM), muscle weakness, and hemiplegia to the left side. The resident had a stage four pressure ulcer to the sacrum and a stage three pressure ulcer to the left shoulder. Staff were to turn and reposition the resident every two hours and check the resident for incontinence episodes and soiled bedding every hour. Review of the documentation for August and September 2024, revealed no evidence that staff turned and repositioned the resident every two hours on 11 of 78 shifts in August and 22 of 78 shifts in September and no evidence that staff checked the resident for incontinence and soiled bedding throughout 10 of 78 shifts in August and 19 of 78 shifts in September. There were no documented refusals. There was no documented evidence that a weekly skin assessment was completed since May 2024. Clinical record review revealed that Resident 2 had diagnoses that included PCM, anemia and muscle weakness. The resident had an unstageable pressure ulcer to the left heel. There was no documented evidence that a weekly skin assessment was completed since March 2024. A physician's order dated May 7, 2024, directed staff to apply a heel boot to the left foot when the resident was in and out of bed. On October 2, 2024, at 11:17 a.m., 11:58 a.m., and 1:04 p.m., the resident was observed in bed; the heel boot was not in place. In an interview at 11:58 a.m., the licensed practical nurse (LPN 1) who was assigned to the resident, confirmed that the heel boot was not in place. In an interview at 1:25 p.m., the Director of Nursing (DON) stated that the heel boot should have been applied as ordered. Clinical record review revealed that Resident 3 had diagnoses that included multiple sclerosis, anxiety, and anemia. The resident had a stage four pressure ulcer to the sacrum. Review of the care plan revealed that the resident had a self-care performance deficit and was totally dependent on staff for bed mobility. Review of scheduled tasks revealed that staff were to reposition the resident every two hours. In an interview on October 2, 2024, at 11:50 a.m., the resident stated that staff did not regularly offer to turn and reposition her in bed, she preferred to be repositioned for comfort, (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: 395077 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 395077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Spring Rehab and Care Center 1113 North Easton Road Willow Grove, PA 19090 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)