Pennsylvania Department of Health
WILLOWBROOKE COURT AT GRANITE FARMS ESTATES
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLOWBROOKE COURT AT GRANITE FARMS ESTATES - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a State Licensure survey and Civil Rights Compliance survey completed on April 12, 2024, it was determined that Willowbrooke Courts at Granite Farme was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:
Based on facility policy and procedure review, staff interview and resident record review it was determined the facility failed to develop interventions to prevent pressure ulcers for one of 5 residents reviewed causing actual harm to resident 63 when they developed a DTI to the right heel. (Resident 63)

Findings Include:

Review of facility policy and procedure titled Skin Integrity- Impaired revealed a pressure ulcer in avoidable if "development of a pressure ulcer .....because the staff did not do one or more of the following: evaluate the residents clinical condition and pressure ulcer risk factor, define and implement interventions consistent with resident's needs/goals and standard of practice. Monitor and valuate the impact of the interventions, revise the interventions as appropriate."

Review of resident 63's face sheet revealed the resident was admitted to the facility on December 18, 2023 with a diagnosis of a right hip fracture that was surgically repaired and development of a DVT (Deep Vein Thrombosis-blood clot forms in the lower leg, thigh, or pelvis.) in the right leg.

Review of Resident 63's Admission Minimum Data Set (MDS-periodic assessment of resident needs) dated December 24, 2023 revealed the resident needed partial or moderate assistance from staff for all transfers and bed mobility.

Review of Resident 63's Admission Braden Assessment completed on December 18, 2023 revealed the resident was a low risk for developing pressure ulcers.

Review of Resident 63's Braden Assessment (assessment to determine residents' risk of developing pressure ulcer) dated January 8, 2024 revealed the resident had decreased and was now at risk for developing a pressure ulcer.

Review of Resident 63's baseline care plan on admission, dated December 18, 2023 revealed there was a care plan for the risk of developing pressure ulcers but there were no interventions in place to prevent pressure ulcers only to monitor and document skin integrity and for good hydration and nutrition.

Review of Resident 63's comprehensive care plan revealed there was no care plan for the prevention of pressure ulcer developed.

Review of Resident 63's progress notes revealed a nursing entry dated January 11, 2024 at 3:32 p.m. revealed "PT called this nurse into shower room to assess resident's skin. Dark colored brownish/ purple area on right heel found measuring from size 1inch by 2inch."

Review of Resident 63's Initial Wound evaluation and Management Summary completed by the wound specialist, dated January 16, 2024 revealed Resident 63 had an unstageable DTI (Deep Tissue Injury- localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure).

Interview with the Nursing Home Administrator and the Director of Nursing confirmed resident 63 should have been identified as a risk for pressure ulcers and interventions placed prior to the development of the DTI on the right heel.

The facility failed to identify Resident 63 at a risk for pressure ulcers and failed to develop interventions to prevent pressure ulcers resulting in Resident 63 developing a DTI to the right heel.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(d) Resident Care Policies

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service

Plan of Correction - To be completed: 06/11/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.

R63's plan of care contains preventative measures and interventions related to the left heel wound.

Residents whom have had a Braden Scale completed in the last 60 days will be reviewed for appropriate preventative measures by the DON or designee.

Audits will be conducted, by the DON or designee, daily x14, weekly x8 and monthly x4 of residents with Braden Scales completed to verify preventative measures as established. Results to be submitted and reviewed by QAPI team.

Nursing staff will be re-educated on the risk factors of skin integrity breakdown and establishment of preventative care by the ADON or designee.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on clinical record review and staff interview it was determined the facility failed to identify a resident as a fall risk and develop interventions to prevent falls for one of 2 residents reviewed causing actual harm to Resident 67 when they fell causing a laceration resulting in a transfer to the emergency department. (Resident 67)

Findings Include:

Review of Resident 67 facesheet revealed the resident was admitted to the facility on February 27, 2023 with diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).

Review of Resident 67's Therapist Progress and Discharge Summary Dated February 22, 2024 while the resident was still residing in his independent living apartment revealed the resident was at risk for falls.

Review of Resident 67's Adv Skilled Evaluation, dated February 27, 2024 at 11:15 a.m. revealed the resident had unsteady gait and poor balance.

Review of Resident 67's fall risk assessment completed on February 27, 2024 revealed the resident was a low risk for falls.

Review of Resident 67's care plan revealed there was no care plan for falls or interventions developed to prevent falls.

Review of Resident 67's progress notes revealed a nursing entry dated March 6, 2024 at 7:25 p.m. stating "Resident was found in sitting position between his dresser (under the TV) and foot of the bed at 1800. First noticed by Charge nurse. Resident has head injury/abrasion on right side top of the head with moderate amount bleeding .....Resident was sent to ER for further Evaluation and Treatment for fall & head injury"

Further review of Resident 67's progress notes revealed a nursing entry dated March 7, 2024 at 1:34 a.m. stating resident returned from the hospital with all test showing no significant findings and an abrasion to the back of the head.

Interview with the Nursing Home Administrator and the Director of Nursing on April 12, 2024 at 10:30 a.m. confirmed Resident 67 should have been identified as a fall risk on admission and interventions developed to prevent falls.

The facility failed to identify Resident 67 as a risk for falls and developed interventions to prevent falls resulting in actual harm when Resident 67 fell causing injury that required evaluation in the Emergency Department.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Plan of Correction - To be completed: 06/11/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.

R67's plan of care contains preventative measures and interventions related to falls.

Residents whom have had a Fall Risk Assessment completed in the last 60 days will be reviewed for appropriate preventative measures by the DON or designee.

Audits will be conducted, by the DON or designee, daily x14, weekly x8 and monthly x4 of residents with Fall Risk Assessments completed to verify preventative measures as established. Results to be submitted and reviewed by QAPI team.

Nursing staff will be re-educated on the implementation of fall preventative care by the ADON or designee.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:
Based on observation, clinical records review, and staff interviews, it was determined that the facility failed to check oxygen saturation (Spo2- is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) of a resident requiring as needed supplemental oxygen for one of three residents reviewed (Resident 120).

Findings include:

Review of Resident 120's diagnosis list includes Congestive Heart Failure ((a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and Cardiomyopathy (An acquired or hereditary disease of the heart muscle that makes it hard for the heart to deliver blood to the body).

Observation of Resident 120 on April 9, 2024, revealed resident was on supplemental oxygen via nasal cannula at two liters per minute.

Review of Resident 120's nursing progress notes dated March 24, 2024, revealed resident was observed breathing fast with increased respirations. Spo2 was 73%, O2 at 2 liters via nasal cannula administered, O2 level went up to 93%. The physician was notified, and a chest x-ray was ordered revealed minimal right lobe infiltrate (Pneumonia). The resident was ordered with antibiotics.

Review of Resident 120's physician orders dated March 28, 2024, revealed an order for oxygen via nasal cannula at two liters per minute to keep Spo2 above 90% as needed for low Spo2.

Review of Resident 120's clinical records failed to reveal Resident 120's Spo2 was regularly monitored/checked to determine if Spo2 was below 90% thus requiring a need for supplemental oxygen.

Review of Resident 120's nursing progress notes dated April 5, 2024, at 3:31 a.m., revealed resident was on oxygen, Spo2 drops to 80% when oxygen is off, resident had been anxious on the previous shift per report.

Interview was conducted with licensed nurse Employee E4 on April 10, 2024. Employee E4 reported that Resident 120 requires supplemental oxygen via nasal cannula due to an episode of low Spo2. When asked how often Resident's Spo2 was checked/monitored, Employee E4 was not able to provide an answer.

Review of Resident 120's April 2024 Treatment Administration Record revealed Resident 120 was ordered with continuous oxygen at two liters via nasal cannula and to check resident's Spo2 every shift for low Spo2. The orders were made on April 10, 2024, after concerns were brought to the facility.

Interview with the Director of Nursing on April 12, 2024, was conducted. The DON confirmed that Resident 120's Spo2 should have been regularly monitored to determine if Spo2 was below 90% thus requiring supplemental oxygen.

28 Pa. Code: 211.5(f) Clinical records

28 Pa. Code: 211.12(d)(1)(5) Nursing service

Plan of Correction - To be completed: 06/11/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.

R120's O2 order was corrected to reflect a routine spO2 level.

Current residents with O2 orders will be reviewed for the need of monitoring spO2 parameters by the DON or designee.

Oxygen orders will be audited daily x14, weekly x8 and monthly x4 to verify that parameters have been added where needed by the DON or designee.

Licensed nurses will be re-educated on the procedure of monitoring spO2 of residents with supplemental O2 by the ADON or designee.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:
Based on clinical record review, and staff interview it was determined the facility failed to complete accurate assessments for one of the three residents reviewed (Resident 10).

Findings include:

A review of Resident 10's nursing progress notes dated February 28, 2024, at 12:25 p.m., revealed resident was discharged to OBT (assisted living) after completing a stay for a fall with a left rib fracture. Denied pain upon leaving the unit, all personal belongings, medications, and appropriate forms were sent with the resident, accompanied by the wellness nurse.

A review of Resident 10's Discharge Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated February 28, 2024, revealed that the resident was discharged to a short-term general hospital.

An interview with licensed nurse Employee E3 was conducted on April 11, 2024, at 10:40 a.m. Employee E3 confirmed that Resident 10 was discharged to assisted living and was not hospitalized. Employee E confirmed that the resident discharge status was coded incorrectly.

The facility failed to ensure Resident 10's discharge status was accurately assessed.

28 Pa. Code: 211.5(f) Clinical records

28 Pa. Code: 211.12(d)(1)(5) Nursing services

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