Health 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. Page 1 of 5 396017 396017 09/09/2024 Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040

F 0552 28 Pa. Code 211.12(d)(1) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 396017 Page 2 of 5 396017 09/09/2024 Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on two of two nursing units (First floor and Second floor). Findings include: An initial tour of the facility on September 9, 2024, 10:00 a.m. revealed the following observations. Observation of facility room [ROOM NUMBER] revealed there were strong odor of urine in the room, the commode was not emptied and cleaned, there were urine, feces, and bathroom tissue in the commode. Interview with the Resident R2 at the time of the observation stated it was from the night before. Observation of facility room [ROOM NUMBER] revealed there were trash on the floor, under the bed such as used medicine cups, alcohol wipes, gauze and tape with blood dripping to the floor, there was yellow stain on the sheet near the foot of the bed, used PICC line dressing cleaning materials, old foam coffee cup with dried stain outside appeared from the day before. Interview with the Employee E4, Registered Nurse at the time of the observation confirmed the findings. Observation of lower number room side of the second floor revealed there were strong odor of urine. Observation of facility room [ROOM NUMBER] revealed there were trash on the floor, gloves on the floor next to the bed, used gauze with tape on the floor. The window bed of the room had multiple cords tangled together which made it hard for the resident in the room to access that side of the bed. There was nebulizer mask on the nightstand without being bagged. Interview with the Employee E3, Guest Service Staff, at the time of the observation confirmed the findings. Observation of the corridor handrail revealed the following findings, There was loose/missing/broken handrail in the corridor next to room [ROOM NUMBER] (missing end piece), loose/broken next to 220, 219, 216, 213, 224, 221, 223, 228, 227, 116, 122, 123, 124 and first shower room. 28 Pa. Code: 201.29(j)(k) Resident rights. 28 Pa. Code: 207.2(a) Administrator's responsibility. 396017 Page 3 of 5 396017 09/09/2024 Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of clinical records, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were safely stored for three of three residents reviewed (Resident R3, R4 and Resident R5). Findings include: Observation of the Resident R3's room conducted on September 9, 2024, at 10:49 a.m. during the tour revealed Fluticasone nasal spray on resident's bed side table. Review of clinical record for Resident R3 revealed no evidence that the facility conducted an assessment for Resident R3 for safe self administration of medication or care planned to store medication in his room. Observation of the Resident R4 room conducted on September 9, 2024, at 11:00 a.m. during the tour revealed 1 bottle of Nystatin antifungal powder and 2 Albuterol inhaler on resident's bed side table. Review of clinical record for Resident R4 revealed no evidence that the facility conducted an assessment for Resident R4 for safe self-administration of medication or care planned to store medication in her room. Interview with the Employee E4, Registered Nurse at the time of the observation confirmed the findings. Observation of the Resident R5 room conducted on September 9, 2024, at 11:19 a.m. during the tour revealed a bottle of Melatonin in her nightstand drawer. Interview with the Employee E3, Guest Service Staff, at the time of the observation confirmed the findings. Review of clinical record for Resident R5 revealed no evidence that the facility conducted an assessment for Resident R5 for safe self-administration of medication or care planned to store medication in her room. 28 Pa. Code 201.8(b)(l) Management 28 Pa. Code 211.12(d) Nursing services 396017 Page 4 of 5 396017 09/09/2024 Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040

F 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of two nursing units observed (First and Second floor nursing units). Residents Affected - Some Findings include: Observation of the corridor handrail revealed the following findings: There was loose/missing/broken handrail in the corridor next to room [ROOM NUMBER] (missing end piece). There were loose/broken handrail next to resident room [ROOM NUMBER], 219, 216, 213, 224, 221, 223, 228, 227, 116, 122, 123, 124 and first shower room. Interview on September 9, 2024, at 12:00 p.m. the Nursing Home Administrator confirmed that handrails were broken or missing, and she would have the maintenance correct the issue. 28 Pa Code 201.14(a) Responsibility of licensee 396017 Page 5 of 5