Health inspection·May 28, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policies, facility documentation, and staff interviews, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of one medication storage room reviewed. (Pine nursing unit) Finding include: Review of the facility policy on Storage and Expiration Dating of Medications, Biologicals, revised on August 7, 2023, indicated that facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. Review of clinical records of Resident R59, revealed that the resident was admitted to the facility on [DATE], with diagnoses including adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Review of Resident R59, January 2024 physican orders revealed an order January 4, 2024 for the anti-anxiety medication Lorazepam Intensol Oral Concentrate 2 MG/ML, give 0.25 ml, 0.5 mg, by mouth every 6 hours as needed for anxiety for 14 days. A review of facility investigation report revealed that on Friday January 5, 2024, nursing received a 30 ml bottle of liquid Ativan for the resident. It was received in a sealed bottle. No dose of Ativan were given to the resident on January 5th,6th, or 7th of 2024. The registered nurse working the 11-7 shift on January 7th, 2024, into January 8th, 2024, stated that she went to give a dose to the resident during the night; however, noticed that the bottle appeared to have been tampered with and was missing 14 MLs of medication. Continued review of the investigation report indicated that, obtained staff statements. Narcotic count was completed at the start of the 11-7 shift on January 7, 2024; however, the oncoming nurse (11-7) failed to go to the refrigerator with the 3-11 nurse to check the Ativan vial. The 3-11 nurse assumed she checked the Ativan because she came and signed off on the controlled drug inventory sheet that the count was correct. The 3-11 nurse reports that the vial of Ativan was full. The 3-11 and 11-7 nurses both report that the medication keys were never out of their possession. The 11-7 nurse is unable to provide an account of what occurred with the missing Ativan as she did not verify the contents at the start of her shift. She stated that she realized there was a problem with the vial when she went to get it from the refrigerator to administer to the resident. Toxicology screen completed for the nurse who reported the missing medication and was negative for Benzodiazepams. The 11-7 nurse is the presumed perpetrator; however, facility cannot definitively conclude that she was (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: 395495 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 395495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court-Spring Hous 728 Norristown Road Lower Gwynedd, PA 19002 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)