Inspection·September 9, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records reviewed, and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one out of three sampled residents (Resident R1). Residents Affected - Few Findings include: Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated August 21, 2024, indicated the diagnose of cognitive impairment (a condition impacting decision making and memory), and dementia (a decline in cognitive abilities that can impact a person's ability to perform everyday tasks). Further review of the MDS indicated that the resident BIMS (Brief Interview for Mental Status) assessment was not completed due to poor cognitive status. Review of Resident R1's care plans dated August 15, 2024, indicated impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Dementia. Review of physician progress note dated August 15, 2024, revealed that resident elected her daughter to make medical decisions on her behalf in the event she was unable to. Interview with Resident R1's daughter on August 15, 2024, stated facility started resident on Melatonin, a sleep aid, without consulting with her. Resident's daughter stated she believed the medication made the resident sleepy that she did not want to get out of bed for bathroom and other activities. Daughter stated she found out about the medication only last Friday when she asked the nurse what she was taking that make her sleepy. Review of Resident R1's physician progress notes dated August 27, 2024, revealed that a new order for Melatonin was ordered as sleep aide. Further review of the physician progress note revealed no evidence that the resident's daughter or other representatives was notified of the new order, discussed the advantage and disadvantage of medication and alternative options. Interview with the Director of Nursing, on September 9, 2024, at 12:50 p.m. the Director of Nursing (DON) confirmed that the facility did not inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for Resident R1 on August 27, 2024. 28 Pa. Code 201.29(j) Resident rights. (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 5 Event ID: 396017 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 396017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040 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)