Inspection·May 11, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide appropriate staff supervision resulting in a fall for one of the nine residents reviewed (Resident 161). Findings include: A review of Resident 161's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 5, 2023, revealed resident was cognitively impaired. The same MDS revealed resident required extensive with two people assistance with transferring. Review of the resident's ADL (activities of daily living) care plan revealed an intervention as follows: Transfer-require extensive assistance by two staff to move between surfaces. Review of the nursing progress notes dated February 8, 2023, revealed the resident's leg buckled and was lowered to the floor during transfer. Review of the facility's documentation, Incident Report dated February 8, 2023, revealed that at 4:40 p.m., Nursing Assistant (NA) reported to the nurse that while assisting the resident off the toilet, the resident's legs buckled and were lowered to the floor. NA's statement dated February 8, 2023, revealed that at around 4:00 p.m., the resident was assisted to go to the toilet, when it was time to get him up, the resident stood up again, but his/her legs gave out and he/she was lowered to the floor. The nurse was called and together assisted the resident back to the chair. No injury was sustained. The care plan was updated on February 9, 2023, to use a total lift for transferring with two staff assistants. An interview with the Nursing Home Administrator on May 11, 2023, at 11:00 a.m., confirmed that the facility failed to provide appropriate supervision of a two-person staff for Resident 161 during a transfer resulting in a fall. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395736 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 395736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court-Granite 1343 West Baltimore Pike Media, PA 19063 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 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. Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a wound treatment medication order was available for one of the 13 residents reviewed (Resident 159). Finding Include: Review of the facility's policy titled Pharmacy Services revealed, that the pharmacy ensures the provision of pharmaceutical services in an accurate, effective, and safe manner. Also, to provide routine and emergency medications and supplies to meet the needs of each resident following state and federal guidelines. Review of Resident 159's physician order sheet revealed an order on May 2, 2023, for A Dakin's solution to sacral wound, wet to dry cover with dressing daily. Review of the nursing progress notes dated May 3, 2023, at 11:32 a.m., revealed Dakin's not on hand, physician was made aware. Review of the nursing progress notes dated May 5, 2023, at 8:10 a.m., revealed Dakin's solution was not available from the pharmacy, will follow up. Review of the May 2023, Treatment Administration Record (TAR) revealed the ordered Dakin's solution treatment to the resident's sacral wound was not done from May 3, 2023, until May 8, 2023. Review of the pharmacy records revealed that Dakin's solution ordered on May 2, 2023, was not delivered to the facility until May 8, 2023. Interview with the Nursing Home Administration conducted on May 11, 2023, at 11:00 a.m., confirmed the Dakin's solution treatment to the resident sacral wound was not followed due to the unavailability of the medication. The facility failed to ensure medication for wound treatment to Resident 159 sacral wound was available. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395736 If continuation sheet Page 3 of 3