Health inspection·November 17, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to obtain or follow physician orders for four of 40 residents reviewed. (Residents 19, 72, 134, and Resident 156) Residents Affected - Some Findings include: Review of Resident 19's physician orders revealed an order dated May 8, 2023 for Tramadol Tablet (narcotic pain reliever) 50 milligrams (mg) give half a tablet by mouth two times a day for pain. Further review of Resident 19's physician orders revealed an order dated June 14, 2023 for Lorazepam (antianxiety medication) 0.5 mg tablet give one tablet by mouth two times a day for anxiety. Review of Resident 19's progress notes revealed a nurse's note dated October 21, 2023, which stated: Noted during am count of narcotics the resident received duplicate dose of [Lorazepam] 0.5mg and Tramadol 25mg between the hours of [6:00 p.m. - 8:00 p.m.] Review of Resident 19's Controlled Drug Receipts revealed Licensed Nurse Employee E3 signed out the resident's Tramadol and Lorazepam on October 20, 2023, at 6:00 p.m. Review of Resident 19's October Medication Administration Record (MAR) revealed Licensed Nurse Employee E3 did not sign the medications out as being administered on the MAR. Further review of Resident 19's Controlled Drug Receipts and October MAR revealed the next shift nurse saw that the medications were not administered per the MAR, and therefore the resident was given additional doses of the medications. Interview with the Nursing Home Administrator on November 17, 2023, at 11:25 a.m. confirmed the above findings. Review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Tablet (stool softener) Delayed Release 5 mg Give 2 tablet by mouth every 24 hours as needed for Constipation. Bowel protocol - give on day 3 as needed. Further review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation. Bowel protocol -give on day 4 as needed. Review of Resident 72's bowel movement records revealed the resident had no bowel movement from Page 1 of 3 395956 395956 11/17/2023 Glen at Willow Valley 675 Willow Valley Square Lancaster, PA 17602

F 0684 October 20 2023 on evening shift until October 26, 2023 on day shift. A total of 6 days. Level of Harm - Minimal harm or potential for actual harm Review of Resident 72's Medication Administration Record revealed Resident 72 was administered the Dulcolax tablets after 5 days of no bowel movement on November 25, 2023 at 7:46 p.m. and was documented as ineffective. Further review of the Medication Administration Record for October 2023 revealed Resident 72 was not offered the suppository. Residents Affected - Some Further review of Resident 72's bowel movement record revealed the resident had no bowel movement from November 9, 2023 on day shift until November 15, 2023 on day shift, a total of 6 days. Review of Resident 72's Medication Administration Record revealed Resident 72 administered the Dulcolax tablets after 5 days with no bowel movement on November 14, 2023 at 10:01 a.m. and was documented as effective however there was no bowel movement documented on the bowel movement record on November 14, 2023. Further review of the Medication Administration record for November 2023 revealed Resident 72 was not offered the suppository. The facility failed to follow physician orders for bowel protocol by not administered bowel medication after 3 or 4 days of no bowel movement as ordered. Review of Resident 134's diagnosis list includes End Stage Renal Disease (ESRD- kidneys no longer function well enough to meet a body's needs), and Hypotension (Low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood). Review of Resident 134's clinical record revealed resident receives Hemodialysis (procedure where a machine and a special filter are used to clean your blood) two times a week, every Monday and Friday. Review of Resident 134's Physician's Order Sheet (POS) dated October 18, 2023, revealed an order for a daily weight before breakfast, to call the physician for a weight gain of two pounds in one day and three pounds in three days. Review of Resident 134's October 2023, Medication Administration Record (MAR) revealed no documented evidence that the resident's daily weight was taken on the following dates: October 19, 20, 21, 23, 26, 29, and 30, 2023. Review of Resident 134's November 2023, MAR revealed no documented evidence that the resident's daily weight was taken on the following dates: November 2, 5, 6, 7, and November 14, 2023. Review of Resident 134's weight and vitals record revealed a weight of 131.2 pounds on October 24, 2023, and 134.7 pounds on October 27, 2023, a 3.5-pound weight gain in three days. In addition, a weight of 133 pounds was identified on November 10, 2023, and 135.7 pounds was identified on November 11, 2023, a 2.7 weight gain in a day. Review of Resident 134's clinical record failed to reveal the physician was notified of Resident 134's identified weight gains. Interview with the Director of Nursing on November 17, 2023, at 11:00 a.m., confirmed that the physician's order regarding daily weights was not followed. 395956 Page 2 of 3 395956 11/17/2023 Glen at Willow Valley 675 Willow Valley Square Lancaster, PA 17602

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 134's POS/progress notes dated November 8, 2023, revealed Acute visit to review BP (blood pressure), Amlodipine (a medication to treat increased blood pressure) 2.5 mg PO (by mouth) daily discontinued in hospital mid-October due to concern for low BP with fall (? Decreased fluid volume due to dialysis). The physician ordered to start Amlodipine 2.5 mg by mouth on non-dialysis days daily hold SBP (Systolic Blood Pressure) < 130 mm hg. Residents Affected - Some Review of the November 2023, MAR revealed Resident 134 was administered with Amlodipine 2.5mg without checking blood pressure on the following dates: November 9, 11, 12, 14, 15, and 16, 2023. Interview with the Director of Nursing was conducted on November 17, 2023, at 11:00 a.m. The DON reported that the physician's order is faxed to the pharmacy and transcribed into the EMR (Electronic Medical Record), the nurse on duty verifies/checks the order. The DON reported that the agency nurse did not ensure that the blood pressure parameter order was transcribed into the resident's EMR and therefore Amlodipine medication was administered without first checking the resident's blood pressure thus determining if the medication needed to be held. The DON confirmed that the facility did not follow the physician's order regarding blood pressure parameters. Review of Resident 156's progress notes revealed a nursing entry dated October 8, 2023 stating Assessed resident's surgical wound and found 4cm (centimeters) X 1.5cm yellowish/macerated (the process of skin softening and breaking down as a result of prolonged exposure to foreign fluids) area at very bottom of incision site and low-grade temp of 99.9 spoke to on call PA-C (physician assistant) who advised to send resident to ER (emergency room) for prompt treatment. Further review of Resident 156's Progress notes revealed the resident returned to the facility on October 9, 2023. Review of resident readmission nursing assessment dated [DATE] at 4:40 p.m. revealed mid back surgical scar with scabs .area at distal (bottom) portion measures 3.0 x 1.0 with opening draining serosanguinous (mixture of blood and clear fluid) fluid in moderate amount on 2x2 dressing (2 inch by 2 inch square of sterile gauze). Area redressed to collect and further drainage for now. Review of resident 156's physician orders revealed an order dated October 10, 2023 for Use soap and water to clean back incision then pat dry and leave OTA (open to air). Further review of resident 156's physician orders revealed there was an order dated October 14, 2023 for Santyl ointment (removed damaged tissue from wounds) apply to lower back surgical wound topically every day shift. The facility failed to provide wound care to an open wound on a surgical site from when resident 156 was readmitted to the facility on [DATE] until October 14, 2023 when the order for Santyl was completed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395956 Page 3 of 3