Every finding on record at Willowbrooke Court Skilled Care Center at Brittany

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to implement physicians' orders for two of 18 sampled residents. (Residents 25, 219) Findings include: Clinical record review revealed that Resident 25 had diagnoses that included Parkinson's disease and hypotension (low blood pressure). A physician's order dated February 18, 2025, directed staff to administer a medication (midodrine hydrochloride) three times a day for hypotension. The medication was to be held 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 140 millimeters of mercury (mm/Hg). Review of Resident 25's medication administration record revealed that staff administered the medication one time in April 2025, once in May 2025, and once in June 2025, when the resident's SBP was greater than 140 mm/Hg. The medication was withheld and should have been administered twice in May 2025 when the resident's SBP was below 140 mm/Hg. Clinical record review revealed that Resident 219 had diagnoses that included heart failure and diabetes. A review of a nursing note from June 30, 2025, revealed the resident was alert, oriented, and able to make his needs know. A physician's order dated June 30, 2025, directed staff to apply compression stockings in the mornings and take them off at bedtime. A nutrition note dated June 30, 2025, indicated that Resident 219 had mild edema in his bilateral lower extremities, was prescribed a diuretic medication, and had orders to wear the compression stockings to his lower extremities. Observations on July 1, 2025, at 11:18 a.m., from 12:15 p.m. to 12:45 p.m., and at 1:45 p.m., revealed Resident 219 was not wearing compression stockings. Observations on July 2, 2025, at 12:13 p.m., revealed Resident 219 was wearing his compression stockings. In an interview with the resident and his family member, it was revealed that was the first time he wore the compression stockings since admission to the facility. In an interview on July 3, 2025, at 9:36 a.m., and 10:00 a.m., the Administrator confirmed that medications were administered outside of the established parameters for Resident 25 and that the compression stockings should have been on Resident 219. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observations, and staff interview, it was determined that the facility failed to properly serve food and maintain sanitary conditions in the one of two dining rooms. (First floor dining room) Findings include: Review of the facility policy entitled, Personal Appearance Standards, last reviewed March 11, 2025, revealed that male staff with facial hair, moustache, and/or beard, must wear a beard guard while in the production kitchen, and defines the production kitchen as the area as where food is prepared or plated from a hot or cold workstation. Observation of meal service in the first-floor production kitchen on July 1, 2025, from 12:15 p.m. to 12:45 p.m., and July 2, 2025, at 8:20 a.m. to 8:35 a.m., revealed the Nutrition Service Manager had a beard, was working in the production kitchen during the lunch and breakfast meal services, and was not observed wearing a beard guard. Observations on July 2, 2025, from 12:10 p.m. to 12:30 p.m., revealed the Nutrition Service Manager was working in the production kitchen during the lunch meal service and was wearing a surgical mask. His facial hair was observed uncovered out of the sides of the mask. In an interview on July 3, 2025, at 9:30 a.m., the Administrator stated that the Nutrition Service Manager should have had a beard guard on in the production kitchen. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain sanitary conditions in the dietary department. Findings include: Review of the facility policy entitled Cleaning and Sanitation Culinary Nutrition Department, last reviewed April 11, 2023, revealed that a regular schedule of cleaning was to be developed and posted for employees to maintain cleanliness and sanitation of the culinary nutrition services department. The procedure was for the culinary services manager to initiate the cleaning schedule and supervise employee compliance to the schedule. All cleaning tasks were to be checked nightly to ensure that they met standards. Observations during the environmental tour of the kitchen on July 11, 2023, at 9:34 a.m., revealed the following: The steel back splash of the main service oven was splattered and stained with a black substance behind the burners on the stove. The fryer was soiled with grease and oil. The warmer device located over the fryer was also soiled with grease and oil. The main grill had heavily soiled rags that were stored beneath the grill in a dry metal bin. The rags were not in any type of sanitizing solution. The main grill was soiled with a black substance. The ceramic tiles behind the walls of the main cooking area were soiled with splattered grease and oil. The floors were soiled with crumbs and debris behind, around and on the sides of the ovens. There was a steel divider between the ovens that was also soiled and stained with a black substance. Further observations revealed that there was a second main service oven on the other side of the kitchen that was heavily soiled with a black substance on the outside of the doors, front of the oven and tops of the oven doors. The inside of this oven was also soiled with crumbs and a black substance. All four convection ovens were heavily soiled with grease and burnt crumbs on the bottom, inside and outside of the ovens. The baking racks inside the ovens were soiled. The glass doors on all four ovens were covered with grease and dark substances. In an interview on July 11, 2023, at 10:00 a.m., the Director of Culinary and Nutritional Services stated that the ovens were to be cleaned weekly. The Director confirmed that the ovens, floors and walls observed during this environmental tour were soiled and in need of cleaning. CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary Previously cited 8/12/22 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the main kitchen on August 9, 2022 at 12:15 p.m., revealed an accumulation of a large amount of small, black insects in and around boxes of sweet potatoes and red skinned potatoes in the dry storage area. The insects were in contact with the food items, the inside of the boxes, and flying around the area. In the walk in freezer, there were two boxes of shrimp, one box of strawberries, and one container of strawberry sherbet that were stored directly on the floor. In a walk-in refrigerator, there was a container with multiple raspberries with a white substance, resembling mold, on the surface of the fruit. In a second walk in refrigerator, there was an accumulation of a dark colored substance in a puddle under a storage shelf that contained raw meat, the substance extended onto other areas of the refrigerator floor. There were various particles of debris as well as multiple pans, a metal bowl, and a pair of tongs on the floor under a rack of clean pots and pans. 28 Pa. Code 201.18(b)(3) Management.

Based on observation it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. Findings include: Observation during the environmental tour of the nursing care service kitchen on (MONTH) 16, 2019, at 9:30 a.m., revealed inside the walk-in freezer one tray of bacon lardons, two trays of crab cakes, two bars of cheese, three unknown frozen items, seven gallons of ice cream and one package of fish that had not been dated, labeled or resealed properly. On the same day at 9:45 a.m., observation inside the walk-in produce refrigerator revealed a yellow substance on the floor underneath a box of pineapples, and a rotten green pepper on the shelf. Inside the walk-in refrigerator there were two plates of thawed fish that were not labeled or dated. Observation of the dry storage area at 10:05 a.m., revealed two trays of tart lids (pastry) that had not been dated and resealed properly.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement care planned interventions for one of 18 sampled residents. (Resident 64) Findings include: Clinical record review revealed that Resident 64 had [DIAGNOSES REDACTED]. On (MONTH) 27, 2108, clinical documentation revealed that the resident had neck pain and was to be evaluated by physical therapy. Physical therapy evaluated Resident 64 on that same day and the resident was to be seen three times a week for stretching and range of motion modalities. On (MONTH) 25, 2019, physical therapy services ended with recommendations for the resident to perform active range of motion activities and participation in group exercise classes to support the resident's return to her prior functional status. There was no clinical documentation to support that care plan interventions had been developed or implemented to support physical therapy goals for ongoing active range of motion. In an interview on (MONTH) 19, 2019, at 11:15 a.m., the Director of Nursing confirmed that recommended active range of motion interventions were not developed. 28 Pa. code 211.12(d)(1)(5) Nursing services

Based on clinical record review and facility policy review, the facility failed to ensure that one of 18 sampled residents did not receive pain medication without adequate indications for its use. (Resident 51) The findings include: Review of the facility policy entitled Pain Management dated (MONTH) 2019 revealed that prior to administration of as needed (PRN) pain medication, staff was to assess the resident's level of pain and then document the assessment on the Pain Scale. Clinical record review revealed that Resident 51 was admitted to the facility on (MONTH) 24, 2019, and had [DIAGNOSES REDACTED]. On (MONTH) 24, 2019, the physician ordered [MEDICATION NAME]-[MEDICATION NAME], one tablet every 4 hours as needed for moderate to severe pain (pain scale score of 4 or above.) Review of the resident's care plan revealed that staff were to monitor and record the resident's pain characteristics, the location of the pain, when the pain began, and the length of time the resident had been experiencing the pain. Review of nursing documentation revealed that on (MONTH) 17, 2019, the resident was yelling continuously help me and said she feels like she is in ceiling and she wants to come down, she wants to be on floor. There was no documented evidence at that time that the resident was experiencing pain. Review of the (MONTH) 2019, Medication Administration Record [REDACTED]. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and review of incident reports, it was determined that the facility failed to adequately assess, document and analyze factors in order to prevent injuries for one of 18 sampled residents who were at risk for skin tears. (Resident R64) Findings include: Clinical record review revealed that Resident R64 had [DIAGNOSES REDACTED]. Review of the current plan of care revealed that the resident was at risk for skin tears and had a history of [REDACTED]. Documentation into the cause of the incident indicated that the resident may have bumped her arm against a chair during a transfer. Review of a second incident report dated January 3, 2017, at 2:00 a.m., revealed that the resident was found on the floor in her room. The resident was noted to have an XXL skin tear down to the muscle with purpura (bruising) noted on her left leg. The resident also had a skin tear to her left arm. Further review of the incident reports revealed that the facility failed to document or recommend corrective action for the injuries in order to prevent future occurrences of skin tears. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/20/16

Based on clinical record review, it was determined that the facility failed to timely implement a pharmacy recommendation for one of 11 sampled residents. (Resident R70) Findings include: Clinical record review revealed that Resident R70 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician acknowledged the recommendation and documented that the Questran be given at 8:00 a.m., one hour prior to the other medications on May 13, 2016. Review of the Medication Administration Record [REDACTED]. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of the infection control policy and staff interview, it was determined that the facility failed to ensure that respiratory equipment was stored in a sanitary manner in order to prevent the spread of infection on two of four nursing units. (One and Two west). Findings include: Review of the facility "Infection Control Manual Policy and Procedures-Use and Care of Equipment" dated January 13, 2014, revealed that when not in use, cannulas, masks, and humidifiers should be rinsed, dried and stored in a plastic bag. Observation on April 29, 2014, at 1:25 p.m., revealed Resident R33 ambulating on One West hallway with assist of therapy staff, and the nasal cannula was wrapped around the portable oxygen cylinder unbagged. On April 30, 2014, at 11:30 a.m., the same resident was again observed ambulating the One West hallway with the nasal cannula unbagged. Observation on April 29, 2014, at 12:00 p.m., and 2:17 p.m., on April 30, 2014, at 7:00 a.m., and 9:00 a.m., and on May 1, 2014, at 9:14 a.m., Resident R85's nebulizer mask was on the nightstand unbagged. In an interview on May 2, 2014, at 10:20 a.m., the Director of Nursing confirmed that the equipment should be bagged when not in use. CFR 483.65(a) Infection Control 28 Pa. Code 211.12 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on observation during the environmental tour of the food service department, it was determined that the facility failed to maintain sanitary conditions. Findings include: Observation during the environmental tour on June 11, 2013, at 10:27 a.m., revealed grease and dust on the mechanical ventilation (hood) system including the surrounding wall tiles directly over the cooking area. In the production area and dishroom, grout between the floor tiles had eroded resulting in gaps on the floor surface. The floor of a storage room was dirty with bread racks used to keep cases of supplies off the floor. The walls and doors of the food delivery area were dirty and scraped. The dock (receiving area) was dirty with grease.

Based on clinical record review and staff interview, it was determined that the facility failed to implement a physician's order for one of 18 sampled residents. (Resident R42) Findings include: Clinical record review revealed that Resident R42 had [DIAGNOSES REDACTED].) daily. Review of the pharmacy recommendation dated May 16, 2013, revealed that the pharmacist recommended a trial dose reduction of [MEDICATION NAME]. Documentation by the physician dated May 29, 2013, indicated that he agreed with the recommendation and ordered that the resident receive [MEDICATION NAME] XR 37.5 mg. on Monday, Wednesday and Friday and [MEDICATION NAME] XR 75 mg. on other days. Review of the Medication Administration Records for May 2013 and June 2013 revealed that staff failed to implement this order, as the resident continued to receive [MEDICATION NAME] XR 75 mg. daily. In an interview on June 14, 2013, at 8:40 a.m., the Director of Nursing confirmed that staff had failed to implement the physician order. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/25/2012

Based on clinical record review and review of investigative reports, it was determined that the facility failed to ensure that one of 18 sampled residents received the level of supervision to prevent falls. (Resident R81) Findings include: Clinical record review revealed that Resident R81 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had short and long term memory loss and required staff assistance for activities of daily living. From August 19, 2012, to December 27, 2012, the resident had ten falls related to non-compliance and poor safety awareness. On January 18, 2013, the resident was found on the floor in his room and sustained an abrasion to his forehead. The bed alarm was sounding; however, the resident was already on the floor when staff responded. On January 30, 2013, at 2:40 a.m., staff responded to the alarm and found the resident on the floor. The facility continued to utilize alarms for the resident despite awareness that the alarms were ineffective in preventing falls. On February 12, 2013, at 4:30 p.m., Resident R81 attempted to rise from a chair without using his walker and fell sustaining an abrasion on the left side of his head. Three days later on February 15, 2013, at 2:00 p.m., the resident was walking fast in the hallway and tripped and fell face first sustaining a skin tear on his hand and nose. Despite the resident's continued unsafe and impulsive behaviors, review of the facility incident investigation determined "continue current interventions." On February 25, 2013, at 9:50 p.m., staff responded to the bed alarm, and the resident was found on the bathroom floor in his room. The recommendation was to monitor "more often," however the facility failed to establish specific parameters addressing how staff was to monitor "more often." The resident then fell again on February 28, 2013, at 12:15 p.m., in the dining room. Review of the incident investigation revealed "staff will do their best to monitor with transfers and ambulation." However, the resident continued to fall. On March 7, 2013, at 11:30 a.m., the resident independently got out of bed and ambulated without the use of his walker to the nurses' station and fell . The alarm had not sounded and the resident managed to ambulate from his room to the nurses' station before staff intervened. On March 8, 2013, the resident had two falls, one at 4:34 p.m., in the activities lounge and the second fall at 9:15 p.m., when staff responded to the bed alarm and found the resident on the floor and he had hit his head on the door frame. Again, the alarm was ineffective in preventing falls. Three days later, on March 11, 2013, at 10:15 p.m., the resident was found on the floor in his bathroom without his walker. The resident was again found on the bathroom floor on March 17, 2013, at 12:40 a.m., after the staff had responded to the sounding bed alarm. From March 31, 2013 to May 13, 2013, the resident continued to fall nine more times. The facility continued to utilize alarms although ineffective and failed to consistently provide the level of supervision that Resident R81 required to prevent falls. 28 Pa. Code 21.12(d)(5) Nursing services. Previously cited 7/24/2012

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician ordered medication was obtained in a timely manner from the pharmacy for one of 18 sampled residents. (Resident R49) Findings include: Clinical record review revealed that Resident R49 had [DIAGNOSES REDACTED]. Resident R49 had an on-going physician order [REDACTED]. In an interview on June 14, 2013, at 9:44 a.m., the Director of Nursing confirmed that the medication had not been provided to the resident due to being unavailable from the pharmacy. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/25/12

Based on observation during the environmental tour of the laundry, it was determined that the facility failed to ensure that all equipment was functional and clean. Findings include: Observation during the environmental tour of the laundry on June 14, 2013, at 9:15 a.m., revealed dried lint on the tubing behind the washer. A wall vent was coated with lint and the front panel on the storage cabinet was missing. In the dryer room two ceiling lights were not functioning and a dirty wall fan was directed on the clean laundry . 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to ensure that staff demonstrated acceptable hand hygiene while providing resident care on two of four nursing units. (Nursing units 2 East, 1East) Findings include: Observation during breakfast on May 23, 2012, from 8:00 a.m., until 9:00 a.m., on the 2 East nursing unit revealed that residents were being served breakfast in the dining room. NA1 was observed serving several residents their breakfast. NA1 was observed touching residents, and she removed soiled dishware from the tables after residents had completed their meals. NA1 proceeded to touch clean dishware and continued to serve other residents their breakfast. NA1 did not wash her hands after direct resident contact nor did she wash her hands between handling soiled dishware prior to handling clean dishware. Observation during lunch on May 22, 2012, from 12:00 p.m., until 12:40 p.m., on the 1 East nursing unit revealed that NA2 was serving residents from the country kitchen. NA2 delivered the food and touched the plates with her bare hands. While serving the residents she was observed touching the residents and then touched the food (cutting sandwiches in half.) NA2 removed soiled dishware from the tables after residents had completed their first course (soup cups, salad) and then proceeded to touch the clean dishware and continued to serve other residents their lunch. NA2 was not wearing gloves and she did not wash her hands after direct resident contact and food contact nor did she wash her hands between handling soiled dishware and handling clean dishware. 483.65 Infection Control Previously Cited 6/30/2011

Based on personnel file review, review of the facility policy and staff interview, it was determined that the facility failed to ensure that a criminal background check was completed on one of five newly hired employees. (Employee 4) Findings include: Review of the facility's policy "Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention," (dated May 1, 2012) revealed that new employees were to have appropriate background screening per state and federal guidelines. Employee 4 began employment on April 4, 2012, and there was no documented evidence that a criminal background check was completed until May 25, 2012. In an interview on May 25, 2012, at 12:50 p.m., the Administrator confirmed that the background check was not done. 28 Pa. Code 201.18(e)(1)Management. 28 Pa. Code201.19 Personnel policies and procedures.

Based on observation and staff interview, it was determined that the facility failed to ensure that the resident's environment was free of accident hazards on two of four nursing units. (2 East and 2 West) Findings include: Observations on May 22, 2012, at 9:42 a.m., and again on May 23, 2012, at 12:40 p.m., revealed that there were razor blades in the 2 West Spa and a bottle of disinfectant that was potentially hazardous if ingested in the 2 East Spa that were in unlocked cabinets and accessible to residents. Observation on May 22, 2012, at 9:45 a.m., revealed that in the resident's personal laundry area on the 2 East nursing unit, there were two bottles of laundry detergent that were in unlocked cabinets and accessible to residents. Observation on May 23, 2012, from 8:33 a.m., until 8:49 a.m., on the 2 East nursing unit revealed that the medication cart was left unlocked and unattended. There were confused and ambulatory residents who resided on the 2 East and 2 West nursing units. Observation on May 23, 2012, at 8:04 a.m., revealed that RN1 poured medications for Resident R68 into a cup and placed the pills in front of the resident who was seated at the dining room table. RN1 left the pills with the resident without observing the resident taking the medications. There were two other residents seated at the table, Resident R79 and R80 who were both confused and had [DIAGNOSES REDACTED]. Observation on May 23, 2012, at 8:28 a.m., revealed that LPN 1 poured medications for Resident R48 into a cup and placed the pills in front of the resident who was seated at the dining room table. LPN1 left the pills with the resident without observing the resident taking the medications. There was another resident seated at the table, Resident R54, who had a [DIAGNOSES REDACTED]. In an interview on May 25, 2012, the Director of Nursing confirmed that medication carts were to be locked when unattended by staff and that nurses were to directly observe resident's taking their medications. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/30/11

Based on observation, it was determined that the facility failed to maintain confidentiality in regard to resident's health information during medication pass on three of four nursing units. (Nursing units 1East, 1West, 2 East ) Findings include: Observation of the medication pass on May 22, 2012 at 8:49 a.m., revealed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation of the medication pass on May 23, 2012, at 8:10 a.m., revealed the MAR indicated [REDACTED] Observation of the medication pass on May 23, 2012, from 8:33 a.m., to 8:49 a.m., revealed the MAR indicated [REDACTED]. The nurses were not in direct attendance of the medication carts while administering medications, allowing non-authorized individuals access to confidential resident information. 28 Pa. Code 201.29(i) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician ordered medications were available from the pharmacy in a timely manner for two of 17 sampled residents. (Residents R64, CR2) The facility also failed to ensure that physician's orders were obtained to dispense medications to one of three residents who were discharged from the facility. (Resident CR2) Findings include: Clinical record review revealed that Resident R64 had [DIAGNOSES REDACTED]. A hospice recommendation and physician's order dated June 27, 2011, directed that the residents receive an anti-anxiety medication (Valium) via suppository every eight hours as needed for restlessness and agitation. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on June 30, 2011, at 11:55 a.m., the Director of Nursing confirmed that the medication was not provided timely by the pharmacy. Clinical record review revealed that Resident CR2 had [DIAGNOSES REDACTED]. A physician's order dated March 13, 2011, directed that the resident receive a diuretic (Zaroxolyn). Review of the MAR for March 2011 revealed that the medication was not administered until March 14, 2011, because the medication was not available from the pharmacy. In an interview on June 30, 2011, at 11:55 a.m., the Director of Nursing confirmed that the medication was not provided timely by the pharmacy. Clinical record review revealed that Resident CR2's unused medications were dispensed to the resident at the time of discharge; however, there were no physician's orders to dispense the medications at time of discharge. The medications included cardiac medications and medications to control diabetes. In an interview on June 30, 2011, at 11:55 a.m., the Director of Nursing confirmed that medications were not to be sent home with the resident unless ordered by the physician. 28 Pa. Code 211.9(j) Pharmacy services. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/20/10