Willow Grove

Failed to obtain prescribed medications and supplements in a timely manner for 1 resident, putting them at health risk.

The facility failed to complete full assessments within 14 days of admission for Residents 2 and 3. This was a recurring deficiency.

Failed to update negotiated care plans for 2 residents regarding skin integrity and insulin injections.

The facility failed to ensure that Staff C completed specialized training for developmental disabilities within 120 days of hire despite a resident having a primary diagnosis requiring such training.

Failed to complete a full assessment within 14 days of admission for 2 residents.

Failed to coordinate health care for 1 resident, resulting in missed appointments and risk of complications.

Facility staff performed nurse delegated tasks that were not supervised by a registered nurse delegator. Additionally, staff assisted a resident with insulin injections who was capable of self-administration without proper assessment.

Door penetration on the bottom of the door in resident room 7.

Appliances (washers, refrigerators) plugged into powerstrips in the laundry room, program office, and med room.

Smoke alarms exceeding 10 years from date of manufacture.

Extension cords used for permanent fixtures in Room 7 and Room 14.

Emergency light in POD 1 hallway failed to illuminate when tested.

Ceiling penetration (hole) around the fire sprinkler pendent in the kitchen pantry.

Facility failed to monitor fluid and dietary restrictions for 1 resident and failed to monitor chronic skin conditions for 2 residents, placing them at risk of complications.

Facility failed to ensure 4 of 4 sampled staff had completed required annual respirator fit testing.

The facility failed to document investigations following incidents that required emergency medical interventions. The administrator began creating a new incident report template during the inspection.

Facility failed to ensure medication administration records were accurate for 4 of 5 sampled residents due to transcription errors and medications not being administered as charted.

Facility failed to update Resident 1's Negotiated Care Plan to reflect current risks and interventions, including aspiration risk and administration of Trulicity.

The facility failed to ensure prescribed medications were renewed and available for administration for 3 of 5 sampled residents (Residents 1, 2, and 5), placing them at risk of health complications.

Facility failed to conduct annual safety assessments for residents using medical devices (Resident 1), failed to update assessments following a change in condition (Resident 4), and improperly utilized state CARE assessments in lieu of facility annual assessments (Residents 4 and 5).

The facility failed to ensure nurse-delegated tasks were performed by qualified and trained staff for 3 of 5 sampled residents (Residents 1, 3, and 4), placing residents at risk of harm and medication errors.

Facility failed to complete a full assessment within 14 days of admission for Resident 2.

The facility failed to provide a resident access to snacks they purchased, violating the resident's right to retain their personal property.

Deletion of specific sentence regarding Staff A and Resident 1 from the Statement of Deficiencies.

Deletion of specific sentence regarding Staff A and Resident 1 from the Statement of Deficiencies.

Addition of interview notes regarding the Negotiated Care Plan and lack of documentation for behavioral interventions.

The facility failed to develop, implement, and provide training on policies to address aggressive behavior related to a medical condition for a resident, resulting in improper physical restraint by untrained staff.

The facility failed to ensure a resident was not restrained by untrained staff on multiple occasions, requiring hospital intervention.

The facility failed to document behavioral interventions in the service plan for a resident with known agitation, leading to a lack of appropriate staff responses and repeated restraint incidents.