Every finding on record at Willow Brook Rehabilitation and Healthcare Center

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to prevent accidents related to falls for one of four sampled residents which resulted in actual harm of a left femoral neck fracture (broken hip). (Resident 1)Findings include: Review of the facility policy entitled, Fall Risk Policy, last reviewed February 23, 2026, revealed that they would complete and update care plans for each resident identified as at risk for falls accordingly. Care plans were to include interventions consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Staff were to monitor the effectiveness of the care plan interventions and modify the interventions as necessary, in accordance with standards of practice. Clinical record review revealed that Resident 1 had diagnoses that included end stage renal (kidney) disease which required dialysis (process of removing excess toxins and water from the blood) and heart failure. According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated April 9, 2026, Resident 1 was dependent on two or more staff to transfer to the bed from the chair (wheelchair). Review of the care plan revealed that Resident 1 was at risk for falls with interventions for staff to anticipate and meet the resident's needs and respond promptly to all requests for assistance. In addition, the care plan identified potential complications related to dialysis with an intervention directing staff to offer the resident to return to bed when returning from dialysis treatments and potential impairment to skin integrity with an intervention directing staff to change, apply lotion and anti-fungal mix to the buttocks, and return the resident to bed upon return from dialysis. On June 1, 2026, staff documented that Resident 1 was found on the floor in her room. The resident was complaining of back pain and left hip pain with palpation (method of feeling with the fingers and/or hands during an exam). On June 1, 2026, the resident was evaluated by the provider. The provider noted that fatigue and weakness likely contributed to the fall. On June 2, 2026, the provider noted that Resident 1's x-ray showed an acute left femoral neck fracture. In a written statement dated June 9, 2026, the Assistant Director of Nursing (ADON) stated that on June 1, 2026, at 11:15 a.m., Resident 1 was sitting in the wheelchair, had just returned from dialysis, used the call bell, and requested to go to bed. The ADON stated that she asked the resident to stay in the wheelchair for lunch. The ADON asked Nurse Aide (NA) 1 to advise the resident's assigned aide, NA 2, to put the resident to bed after lunch. In an interview on June 18, 2026, at 1:15 p.m., the ADON stated that lunch arrived on the unit and was delivered to Resident 1 at 11:20 a.m. The ADON confirmed she told NA 1 to tell NA 2 to put Resident 1 in bed after lunch and that Resident 1 required two staff to transfer from the chair to the bed with the mechanical lift. The ADON stated that the lunch meal was typically completed in 30 minutes. In a written statement dated June 1, 2026, Registered Nurse (RN) 1 stated that they answered the call bell for Resident 2, who stated Resident 1 fell on the floor. RN 1 noted a bruise to the resident's left upper thigh and pain with palpation. The resident was transferred to bed with the mechanical lift and four staff members. Review of facility documentation revealed that the fall occurred at 1:20 p.m. (two hours after the resident had initially requested transfer to bed). The nurse noted bruising on the mid left upper thigh with a slight abrasion measuring 0.5 centimeters (cm) by 0.5 cm. Resident 1 had complaints of left hip pain with palpation and movement with some spasms. The x-ray showed an acute left femoral neck fracture. The provider noted that the resident was not a surgical candidate and was placed on hospice services (end-of-life care). In an interview on June 18, 2026, at 2:15 p.m., the Nursing Home Administrator stated that Resident 1 was left out of bed to eat lunch, staff never returned after lunch to place the resident in bed, and she fell asleep and slid out of the wheelchair. Review of the clinical record revealed no documented evidence that Resident 1 was offered to go to bed after dialysis on the date of the incident. In an interview on June 18, 2026, at 2:20 p.m., the Nursing Home Administrator confirmed that the resident should have been put to bed after returning from dialysis. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on select facility policy review, clinical record review, review of Centers for Disease Control (CDC) guidelines, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate measures for the care and management of a midline peripheral venous access device (a vascular access tool inserted into an upper arm vein to serve as an alternative to a shorter IV for treatment) in accordance with facility policy and professional standards of practice for one of three residents (Resident 8). These failures resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Peripherally Inserted Central Catheter (PICC)/Midline/Central Venous Access Device (CVAD) Dressing Change, last reviewed on February 26, 2026, revealed that the facility was to inspect the catheter-skin junction and surrounding area, palpating through the intact dressing for redness, tenderness, swelling, and drainage, note any pain, numbness, or tingling, and change a midline dressing weekly or if soiled in a manner to decrease potential for infection. Physician's orders would specify the type of dressing and frequency of changes. The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, last updated October 2017, recommends replacing transparent dressings on short-term central vascular catheter (CVC) sites at least every seven days. Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included a severe bone infection (osteomyelitis) at the base of the spine (sacral/coccyx) and an advanced (stage four) sacral region pressure wound. A review of the Minimum Data Set assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 24, 2026, revealed that Resident 8 was cognitively intact, had intravenous access (a method of inserting a thin catheter or tube directly into the bloodstream through the veins for administering fluids, medications, blood products, or nutrition) and was receiving intravenous medication. A physician's order dated February 19, 2026, directed staff to administer two grams of an antibiotic (ceftriaxone sodium) solution reconstituted intravenously daily for treatment of osteomyelitis. Review of Resident 8's Medication Administration Record for February and March 2026 revealed that there were no orders for care and maintenance of the midline access site. Review of the care plan revealed that the resident was at risk for complications related to receiving intravenous medication and included interventions for staff to observe the right chest wall dressing every shift and to change the dressing weekly. Observations on March 24, 2026, at 12:20 p.m. and 2:50 p.m., revealed Resident 8 had a midline peripheral access site in the right chest wall with a transparent dressing dated February 22, 2026, which indicated that staff had not changed the dressing in 30 days. The bottom part of the dressing was not fully adhered to the skin. In an interview on March 24, 2026, at 2:50 p.m., the resident stated that staff had not changed the dressing. There was a lack of documentation to support that the facility had provided adequate care and management of the midline peripheral venous access device, including assessing the resident's access site and changing the dressing at least every seven days and as needed, putting Resident 8 at risk for infection. In an interview on March 24, 2026, at 2:54 p.m., the Director of Nursing confirmed that the dressing for Resident 8's midline access site was dated February 22, 2026, and that it should have been changed weekly. On March 25, 2026, at 2:15 p.m., the Administrator and the Director of Nursing were notified that the failure to implement appropriate measures for the care and management of a midline peripheral venous access device in accordance with facility policy and professional standards of practice resulted in an Immediate Jeopardy situation at F694-J and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on March 25, 2026, at 6:35 p.m. The facility's action plan contained the following: 1. Resident 8 was discharged from the facility. Upon return the facility would review the resident's chart and follow physician's orders.2. Residents with a PICC line will be assessed to assure that appropriate measures for the care and management of a midline peripheral venous access device are in place and ensure that weekly dressing changes are properly ordered by the physician and completed.3. Any residents admitted with a PICC line will be reviewed to assure that physician's orders include weekly dressing changes. RN Supervisor will ensure that orders are in place.4. The Director of Nursing (DON) reviewed the policy and procedures for PICC and wound management policy to ensure professional standards are provided.5. Staff educator/designee will educate licensed nursing staff on the policy and procedure related to care and management of a midline peripheral venous access device and wounds.6. Staff educator/designee will educate licensed nursing staff on obtaining physician's orders when any new skin alteration is identified.7. All staff scheduled for the evening shift (3:00 p.m. to 11:00 p.m.) on March 25, 2026, will be educated with 100 percent of staff on that shift educated by March 25, 2026. 8. All staff scheduled for the night shift (11:00 p.m. to 7:00 a.m.) on March 25, 2026, will be educated with 100 percent of staff on that shift educated by March 25, 2026. 9. All other licensed staff and providers will be educated via telephone education with 100 percent of all staff educated by March 25, 2026.10. Licensed staff who cannot be reached by March 25, 2026, will be removed from the schedule pending completion of education.11. DON/Designee will review new admissions/re-admissions within 72 hours to ensure all physicians' orders are verified. This will be audited weekly for four weeks then monthly for four months. Results will be reported in Quality Assurance and Performance Improvement (QAPI).12. DON/Designee will do random audit of residents with PICC/wounds daily for five days to ensure dressing changes are completed as ordered followed by weekly audits for four weeks, then monthly for four months. Results will be reported to QAPI. The survey team validated that Immediate Jeopardy was removed on March 25, 2026, at 6:40 p.m., through observation, review of the facility training, and staff interviews following the facility's implementation of the plan for removal of the Immediate Jeopardy. The deficient practice remained at scope/severity D (isolated with potential for more than minimal harm) following the removal of the Immediate Jeopardy. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on six of six medication carts. (Unit I Carts 1, 2, 3 and Unit II Carts 1, 2, 3)Findings include: Review of the facility policy entitled, Controlled Substance Administration and Accountability, last reviewed February 26, 2026, revealed that two licensed nurses were to account for all controlled substances at the end of each shift for areas without automated dispensing systems. Review of the controlled substance logs for January, February, and March 2026, for the Unit I and Unit II medication carts (without automated dispensing systems) revealed the following: There was no documented evidence that the controlled substances were counted after every shift on 15 of 31 days from January 1 through 31, 2026. There was no documented evidence that the controlled substances were counted after every shift on 14 of 28 days from February 1 through 28, 2026. There was no documented evidence that the controlled substances were counted after every shift on 11 of 24 days from March 1 through 24, 2026. In an interview on March 25, 2026, at 9:15 a.m., the Director of Nursing confirmed that the nurse coming on duty and the nurse going off duty were to sign that specific cart's Shift Count Log to verify that they counted the narcotics at the end of the shift and that there were no discrepancies with the count. In an interview on March 27, 2026, at 10:38 a.m., the Director of Nursing confirmed that there was no evidence that the controlled substances were counted and signed off on the identified dates as per facility policy and should have been. 28 Pa. Code 211.9(j.1)(5) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for three of 28 sampled residents. (Residents 14, 22, and 70)Findings include: Clinical record review revealed that Resident 14 had diagnoses that included hypotension (low blood pressure), end stage renal disease, and dependence on renal dialysis. A physician's order dated February 4, 2026, directed staff to administer a medication (midodrine) one time a day at 9:00 a.m., for hypotension every Monday, Wednesday, and Friday. A physician's order dated November 16, 2025, directed staff to have Resident 14 leave the facility at 5:30 a.m., to go to dialysis Monday, Wednesday, and Friday. Review of Resident 14's medication administration records (MAR) for February and March 2026, revealed that staff had noted Resident 14 was out of the facility six times in February and 11 times in March, and the medication was not administered. Clinical record review revealed that Resident 14 was at dialysis at those times. There was no evidence that staff notified the physician of the missed doses or that the facility addressed the resident's medication administration schedule to prevent missed doses on dialysis days. Clinical record review revealed that Resident 22 had diagnoses that included diabetes and chronic kidney disease. Physician's orders dated January 18, 2026, and February 3, 2026, directed staff to administer eight units of a diabetic medication NovoLog (insulin aspart) subcutaneously (under the skin) at 7:00 a.m., 11:30 a.m., and 4:30 p.m., 27 units of insulin glargine subcutaneously at 10:00 a.m., and 16 units of a diabetic medication insulin glargine subcutaneously at 9:00 p.m., every day. Staff were not to administer the medication if the resident's blood sugar was less than 120 milligrams per deciliter (mg/dL). Review of Resident 22's February and March 2026 MAR revealed that staff administered the insulin glargine one time in February and three times in March when the resident's blood sugar was less than 120 mg/dL. Further review of Resident 22's March 2026 MAR revealed that staff administered the insulin aspart two times in March when the blood sugar was less than 120 mg/dL. Clinical record review revealed that Resident 70 had diagnoses that included hypotension. A physician's order dated February 28, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg). Review of Resident 70's February and March 2026 MARs revealed that staff administered the medication one time in February and seven times in March when the resident's SBP was greater than 120 mm/Hg. In an interview on March 27, 2026, at 10:36 a.m., the Director of Nursing (DON) stated that if a medication could not be administered, the nurse was to contact the physician of the missing dose by the next day. The DON further confirmed that there was no documented evidence that nursing staff notified the physician that the midodrine was not administered to Resident 14 due to the resident being at dialysis in February and March and that the nurses were to have held the insulin when Resident 22's blood sugar was below 120 mg/dL. The DON also confirmed at that time that Resident 70 should not have received midodrine when the SBP was greater than 120 mm/Hg. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to administer medications in a manner that prevents the spread of infections for one of 28 sampled residents. (Resident 19)Findings include: Review of the facility policy entitled, Administration of Eye Drops or Ointments, last reviewed February 26, 2026, revealed that eye medications were to be administered in accordance with professional standards of practice and gloves were to be applied prior to administration of the eye drops. On March 25, 2026, at 8:50 a.m., Licensed Practical Nurse (LPN) 1 was observed administering medications to Resident 19. LPN 1 administered a medicated eye drop used to treat eye inflammation, swelling, and redness caused by surgery, injury, or allergies (prednisolone 1%) and a medicated eye drop used to treat bacterial eye infections (ofloxacin 0.3%) to the eyes of the resident with her ungloved hands. In an interview on March 26, 2026, at 9:55 a.m., the Director of Nursing confirmed that the nurse should have been wearing gloves to administer medications to the eyes. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during a tour of the kitchen on March 12, 2024, at 9:47 a.m., revealed the following: The inside of the microwave was dirty and splattered with dried food. In the food preparation area, there were two uncovered garbage cans that contained garbage. There was a dirty plastic bag that covered tubing for the juice machine. There was an accumulation of dirt and grease on the side of the grill, underneath the flat top, and surrounding the stove top controls. There was a puddle of water under the steamer. There was debris under the shelves in dry storage. In dry storage, there was a box of chocolate chips with a use by date of February 1, 2024. Observation of multiple cycles of the dish machine while the machine was in use following the breakfast meal service revealed that the final rinse cycle did not maintain a temperature of 180 degrees Fahrenheit for heat sanitization. Following observations of four cycles, the dish machine began to shut off before reaching the final rinse cycle. Dietary Aide 1 (DA 1) attempted to restart the machine three times; the machine shut off before the final rinse cycle on each attempt. DA 1 stated that the dish machine has occasionally shut off before the wash and rinse cycle were complete and the machine occasionally does not achieve the proper temperatures. In an interview on March 12, 2024, at 1:00 p.m., the Registered Dietitian confirmed that the dish machine was not in working order and did not maintain an adequate temperature for heat sanitization. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves, and Ombudsman information, in writing upon transfer from the facility for seven of seven sampled residents who were transferred to the hospital. (Residents 18, 50, 76, 83, 95, 102, and 109) Findings include: Clinical record review revealed that Resident 18 was transferred to the hospital on December 22, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 50 was transferred and admitted to the hospital on December 30, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 76 was transferred to the hospital on December 12, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 83 was transferred to the hospital on December 14, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 95 was transferred to the hospital on February 18, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 102 was transferred to the hospital on October 12 and 24, 2023, after changes in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 109 was transferred to the hospital on March 3, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. In an interview on March 15, 2024, at 9:00 a.m., the Administrator confirmed that residents and/or resident representatives were not given written notice regarding transfers from the facility.

Based on clinical record review, observation, and staff interview, it was determined the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 35) Findings include: Clinical record review revealed that Resident 35 had diagnoses that included dementia, muscle weakness, and difficulty in walking. The Minimum Data Set assessment dated [DATE], revealed that Resident 35 required staff assistance for bed mobility and transfers. Review of the care plan identified that the resident was at risk for falls related to adjustment to a new environment. Review of an incident report dated February 3, 2023, revealed the resident was found on the floor after rolling out of bed. As an intervention staff was instructed to place a fall mat on the door side of the bed. Observations on March 14, 2023, at 11:20 a.m., and at 12:42 p.m., and March 15, 2023, at 9:15 a.m., revealed that Resident 35 was in bed and there was no fall mat placed on the door side of the bed. In an interview on March 16, 2023, at 9:50 a.m., the Director of Nursing confirmed that the floor mat should have been in place. CFR 483.25(d)(2) Free of Accident/Hazards/Supervision Previously cited 4/15/22 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, and staff interview, it was determined that the facility inserted an indwelling urinary catheter without clinical justification for one resident (Resident 15) and failed to assess two residents who were incontinent of bladder to determine if normal bladder function could be restored out of 24 sampled residents. (Residents 10, 15) Findings include: Review of the facility policy entitled, Continence Management Program, last reviewed February 20, 2023, revealed that facility staff was to assess residents who were incontinent to determine which program was most appropriate. Nursing staff was to monitor each resident for three days to determine if there was a pattern to the incontinence, and choose an appropriate program based on that assessment. Review of the facility policy entitled, Indwelling Catheter, last reviewed on February 20, 2023, revealed that residents were not to be catheterized unless the resident's condition demonstrated that catheterization was necessary. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses that included chronic pain and colitis. At the time of admission he was using an external catheter to urinate. Shortly after admission, his external catheter fell off, and staff inserted an indwelling urinary catheter. On February 16, 2023, a nurse practitioner noted that staff was not sure why the catheter was in place. There was no documentation of a clinical reason for the indwelling urinary catheter. On February 17, 2023, staff removed the indwelling urinary catheter. According to the Minimum Data Set (MDS) assessment, dated February 20, 2023, he was frequently incontinent of bladder and was not on a retraining program. After removal of the catheter, there was no documented assess of the resident's continence to determine if normal function could be restored. According to nurse aide records, the resident was often incontinent of bladder since the removal of the catheter. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE]. According to the MDS assessment, dated February 23, 2023, the resident was frequently incontinent of bladder and required extensive assistance from staff to use the toilet. There was no documented evidence of a 3-day bladder diary to determine a pattern of incontinence, nor was there evidence that the facility assessed the resident's incontinence to determine the type of incontinence or if normal bladder function could be restored. According to nurse aide records, the resident had been frequently incontinent since admission to the facility. In an interview on March 16, 2023, at 9:30 a.m., the Director of Nursing confirmed that neither Resident 10 nor Resident 15 was assessed for their incontinence in accordance with facility policy, including a voiding diary and evaluation for a possible retraining program. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to develop a comprehensive care plan that addressed individual resident needs identified on the comprehensive assessment for one of 24 sampled residents. (Resident 69) Findings include: Clinical record review revealed that Resident 69 had diagnoses that included major depressive disorder. Review of the Minimum Data Set assessment dated [DATE], identified that the resident received psychotropic medications. According to the Care Area Assessment the facility identified the resident's psychotropic medication use was a problem and should have been included on the resident's care plan. Review of the care plan revealed that there were no interventions to address the need for psychotropic medications. In an interview on March 16, 2023, at 9:50 a.m., the Director of Nursing confirmed that there was no care plan with interventions developed to address the use of psychotropic medications for Resident 69. 28 Pa. Code 211.11(d) Resident care plan.

Based on observation, resident interview, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on one of two nursing units. (Unit One) Findings include: On January 14, 2023, from 11:40 a.m. through 12:15 p.m., Residents 1, 2, 5, and 6 stated that their meals are consistently cold. Review of facility documentation entitled, Resident Tray Assessment Report, revealed that a score of one point indicated the temperature quality needs improvement and a score of zero points indicated unacceptable quality. A temperature between 120 and 124 degrees Fahrenheit (F) for the hot entree, starch, and vegetable resulted in a score of one. A temperature below 120 degrees F for the hot entree, starch, and vegetable resulted in a score of zero. Results of a test tray audit conducted on January 14, 2023, at 12:30 p.m., revealed a sloppy [NAME] sandwich at a temperature of 122 degrees F, french fries at a temperature of 111.0 degrees F, and mixed vegetables at a temperature of 111 degrees F. The temperatures resulted in a score of one for the sloppy [NAME] sandwich and zero for the french fries and mixed vegetables. On January 14, 2023, from 12:45 p.m. through 1:00 p.m., Residents 7 and 8 were in their rooms with their lunch trays in front of them. In an interview at that time Resident 7 stated that her meal was cold, she did not want to finish it, and that the meals are consistently cold. Resident 8 stated that her lunch was cold and that usually the meals are cold.

Based on observation, staff interview, and review of facility records it was determined that the facility failed to store food under sanitary conditions in the kitchen and on two of two nursing units. (Units one and two) Findings include: Observation of the kitchen on April 12, 2022, at 10:22 a.m., revealed a bag of potatoes stored on the same shelf as raw meat in the walk in refrigerator, and a bag of shredded lettuce with a best by date of March 22, 2022. There was a reddish brown substance on the deflector in the ice machine. In an interview during the observation, the regional director of food service stated the facility maintenance department is responsible for cleaning the inside of the ice machine in the kitchen. Review of the facility ice machine cleaning schedule indicated the ice machines were to be cleaned on the last week of the month, on a monthly basis. Further review of the cleaning schedule revealed no documented evidence that the ice machine in the kitchen was cleaned since March 8, 2022. The dry storage closet had an accumulation of dust and debris and a small remnant of a cigarette on the floor under the shelves. In an interview during the observation, the Regional Director of Food Service confirmed the dietary department was responsible for maintaining the cleanliness of the storage closet. In a reach in refrigerator, there was an open carton of liquid eggs that was not dated and stored on the top shelf of the refrigerator, above ready to eat food items. Observation of the refrigerator on nursing unit one on April 15, 2022, at 10:10 a.m., revealed an open carton of thickened dairy drink and an open carton of thickened water, the containers were not dated. There was a brown stain on the bottom shelf of the refrigerator, there were two slices of bread wrapped in plastic wrap that were not labeled or dated. Observation of the refrigerator on nursing unit two on April 15, 2022, at 10:16 a.m., revealed a red stain on the bottom shelf on the door of the refrigerator. In an interview on April 15, 2022, at 12:57 p.m., the Regional Clinical Support Specialist stated opened cartons of thickened liquids should be dated and used within three days. 28. Pa. Code 201.18(b)(3) Management.

Based on observation, resident interview, review of facility temperature logs, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on one of two nursing units. (Unit One) 33xz Findings include: During the resident group interview conducted on April 13. 2022, at 11:00 a.m., revealed five of five residents complained that food and beverage temperatures were always cold. Review of facility documentation entitled, Resident Tray Assessment Report, revealed that a score of one indicated the temperature quality needs improvement, a score of zero points indicated unacceptable quality. A temperature below 120 degrees Fahrenheit (F) for the hot entree, starch, and vegetable resulted in a score of zero and temperatures below 140 degrees F for hot beverages resulted in a score of zero points. In an interview on April 14, 2022, at 12:13 p.m., the District Manager of Food and Nutrition Services stated that test trays were expected to be conducted two to three times per week, and confirmed test tray audits were not completed as expected for over one month. Results of test tray audit conducted on April 14, 2022, at 12:35 p.m., revealed potato tots at a temperature of 114.0 degrees F, mixed vegetables at a temperature of 111.5 degrees F, and coffee at a temperature of 132.9 degrees F. The temperatures resulted in a score of zero. Review of facility documentation entitled, Service Line Checklist, for the date range of March 1, 2022, through April 14, 2022, revealed no documented evidence that holding temperatures were obtained prior to meal service for the breakfast meal on eight of 45 days reviewed and the lunch meal on 12 of the 45 days reviewed. 28 Pa. Code 201.29(i)(j) Resident rights.

Based on the resident group interview, review of Resident Council meeting minutes, and meal tray temperature observation, it was determined that the facility failed to act promptly to address grievances voiced by the resident group. (Residents 58, 70, 87, 95, 107) Findings include: During an interview conducted with the resident group on April 13, 2022, at 11:00 a.m., five of five residents in attendance complained that food and hot beverages were served cold and that the facility did not act promptly in response to complaints voiced at the resident council meetings regarding dietary services. Review of resident council meeting minutes dated October 5, 2021, November 19, 2021, and March 1, 2022, contained resident complaints, including that food and/or beverage temperatures were too cold. There was a lack of evidence to support that the facility addressed the resident complaints regarding meal temperatures. Food temperatures taken during the lunch meal on April 14, 2022, revealed that hot food/beverage items were not served at adequate temperatures. 28 Pa. Code 201.29(i) Resident rights.

Based on observation and interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 23 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed that the resident was legally blind, had a potential for falls, and had a self-care deficit with interventions for the call bell to be in reach, on the door side of the bed and encourage the resident to call for assistance. On April 12, 2022, at 12:00 p.m., the resident was observed out of bed, sitting in her bedside chair on the door side of the bed. The call bell was observed behind the resident under her bed cover. There was a sign above her bed that indicated the call bell was to be placed on the door side of the bed within reach of the resident. In an interview during the observation, the resident stated, I do not know where my call bell is, it is supposed to be on the side of me. On April 12, 2022, at 12:28 p.m., the resident was again observed out of bed in her bedside chair, the call bell remained behind the resident, under her bed cover. In a subsequent observation on April 12, 2022, at 12:36 p.m., the resident was observed sitting on the door side of her bed in her bedside chair, eating her lunch. The call bell remained behind the resident, under her bed cover, out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview, resident interview, and review of facility policy, it was determined that the facility failed to ensure that each resident was provided the opportunity to formulate an advance directive to determine wishes for care and treatment for two of 23 sampled residents. (Residents 59, 157) Findings include: Review of the facility policy entitled, Resident Rights Regarding Treatment and Advanced Directives, last reviewed February 22, 2022, revealed that the facility would provide the resident or representative information, in a manner, that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. Decisions regarding advanced directives and treatment would be periodically reviewed as part of the comprehensive care planning process, the existing care instructions, and whether the resident wished to change or continue these instructions. Clinical record review revealed that Resident 59 was admitted to the facility on [DATE]. Further review of Resident 59's clinical record revealed there was no code status listed in the electronic medical record. The Resident's living will was dated 2001. There was a lack of documentation to support Resident 59's wishes regarding care were reviewed and to determine whether the resident wished to change or continue the instructions, per facility policy. In an interview on April 15, 2022, at 12:52 p.m., the Director of Nursing stated that there was no code status listed in the electronic or physical clinical record and Resident 59's wishes regarding care were not reviewed prior to April 15, 2022. Clinical record review revealed that Resident 157 was admitted to the faciity on April 6, 2022. During an interview on April 12, 2022, at 12:04 p.m., the resident reported that the facility had not met with him to discuss his wishes regarding care. There was a lack of documentation to support that the resident was provided with information regarding formulation of an advance directive for care. During an interview on April 15, 2022, at 12:53 p.m., the Director of Nursing confirmed that there was no evidence that Resident 157 was provided with information regarding advance directives. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the physician regarding a change in condition for one of 23 sampled residents. (Resident 81) Findings include: Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated April 7, 2022, indicated that the resident went unresponsive during shower activity. There was a lack of documentation to support that the physician was notified of the resident's change in condition. During an interview on April 15, 2022, at 12:56 p.m., the Director of Nursing confirmed that there was a lack of evidence to indicate the physician was notified of Resident 8's change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to ensure a safe, clean, and comfortable environment was maintained in resident rooms on two of two nursing units. (Unit one and two) Findings include: Observation in resident room 225 on April 13, 2022, at 11:05 a.m., revealed a large accumulation of small black insects on the heating and air conditioning unit, in the window sill, in the tracks of the window, on the floor under the window, and along the base of the wall. Observation in resident room 229 on April 13, 2022, at 10:47 a.m., revealed a large accumulation of small black insects on the window sill, on the wall connected to the window, on the floor under the window, and along the base of the wall. In an interview on April 15, 2022, at 10:44 a.m., the Regional Director of Plant Operations confirmed that termites were present in the resident rooms on April 13, 2022. Observation in resident room 130 on April 15, 2022, at 12:10 p.m., revealed a collection of chips, used tissues, and white stains on Resident 13's recliner chair. 28 Pa. Code 207.2(a) Administrator responsibility.

Based on clinical record review, staff interview, and resident and family interview, it was determined that the facility failed to provide assistance with oral hygiene or showers/tub baths for six of 23 sampled residents. (Residents 13, 58, 70, 87, 95, 107) Findings include: Clinical record review revealed that Resident 13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff for personal hygiene. In an interview on April 14, 2022, at 12:15 p.m. Resident 13's family member stated that the resident's teeth are not always cleaned. Review of the current care plan indicated that Resident 13 was dependent on staff for oral care twice a day. Review of facility documentation for March 2022 and April 1 through 14, 2022, revealed that Resident 13 did not receive oral care on 18 occasions. There was a lack of documentation to support that the resident was provided with regular mouth care. During an interview on April 15, 2022, at 1:00 p.m., the Director of Nursing confirmed that there was no documentation to support that oral care was consistently provided to Resident 13. During the resident group interview on April 13, 2022, at 11:00 a.m., five of five residents (Residents 58, 70, 87, 95, and 107) complained that they were not offered the opportunity to take a shower or tub bath twice a week, as scheduled. Clinical record review revealed that residents were to receive showers twice a week according to nurse aide documentation. Review of February and March 2022, bath/shower documentation for a period of eight weeks, revealed a lack of documentation to support that showers/tub baths were offered as scheduled, twice per week (for 16 opportunities), as follows: Resident 58 - four times, Resident 70 - five times, Resident 87 - five times, Resident 95 - six times, and Resident 107 - eight times. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff and resident interviews, it was determined that the facility failed to provide services to prevent a decrease in range of motion for two of 23 sampled residents. (Resident 72, 99) Findings include: Clinical record review revealed that Resident 72 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a limitation in range of motion to both upper (shoulder, elbow, wrist, hand) and lower (hip, knee ankle, foot) extremities, on one side. Review of the care plan revealed Resident 72 had a self-care deficit and was to be on a restorative splinting program. On June 27, 2021, the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on April 13, 2022, at 11:25 a.m., revealed the resident in bed and the splint was on a drawer stand next to the resident's television stand. During a subsequent observation on April 14, 2022, at 10:47 a.m., the resident was in bed, the hand splint was next to the resident on her bedside recliner. In an interview at 10:50 a.m., NA 2 confirmed the resident was not wearing the comfy splint on her left hand. Clinical record review revealed that Resident 99 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that Resident 99 was not cognitively impaired and had a limitation in range of motion to both upper and lower extremities, on one side. Review of the care plan revealed that Resident 99 had a self care deficit and the intervention was for a left resting hand splint to be applied in the [MEDICATION(S)] care and removed with evening care. On March 23, 2022, the physician ordered for a left soft wrist splint to be placed on the resident every [MEDICATION(S)] care and removed with evening care. On April 13, 2022, from 12:10 p.m. through 1:00 p.m. Resident 99 was observed in bed without his left resting hand splint. In an interview at that time, Resident 99 stated that he had not seen the splint in a while and he would like to wear it. On April 14, 2022, at 10:00 a.m. Resident 99 was observed in bed without his left resting hand splint. 483.25(c)(1) Increase/prevent decrease in ROM/mobility Previously cited 5/6/2021 28 Pa. Code. 211.12(d)(1)(5) Nursing services.