Pennsylvania Department of Health
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are 151 surveys for this facility. Please select a date to view the survey results.

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint survey completed on February 27, 2026, it was determined that Glen Brook Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 04/01/2026

F 0684
1. The facility cannot retroactively correct this issue. Resident 7 had no negative impact. Resident 4 had no negative impact.

2. The DON/Designee will review Medication Administration Record (MAR) for residents on midodrine to identify if physician ordered parameters were followed. Any issues will be addressed with physician. The DON/Designee will complete an observational audit of residents with physician ordered therapeutic positioning devices to assure devices are in place per orders.

3. The Licensed nurses will be educated by the DON/designee on the importance of following physician ordered parameters for medications. Nursing staff will be educated by DON/designee on the importance of assuring therapeutic positioning devices are in place per physician orders.

4. EMAR will be reviewed for residents on Midodrine to assure that physician ordered parameters were followed. Audits will be done weekly x 4 then monthly x 3 months then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

An observational audit of residents with physician ordered therapeutic positioning devices will be conducted to assure devices are in place per orders. Audits will be done weekly x 4 then monthly x 3 months then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observations of resident pantry areas and staff interview, it was determined the facility failed to maintain equipment and environmental surfaces in a clean and sanitary condition in areas used for food and ice service to prevent the potential for microbial growth in food and beverages, increasing the risk of foodborne illness and waterborne pathogens in four of four resident pantry areas (East, North, Spruce and Willow pantries).

Findings include:

Observation on February 26, 2026, at 10:25 AM of the resident food pantry located on the East Wing nursing unit revealed the ice machine's condensation drain hose (a hose that transports moisture produced by the ice machine to a floor drain) was visibly soiled with a black substance. The ice dispenser contained a buildup of orange and gray substance and white mineral deposits (hard residue left behind from water) within and around the dispenser opening where ice is dispensed. The pantry sink contained a used food thermometer that was visibly soiled with an orange substance.

Observation on February 26, 2026, at 10:40 AM of the resident food pantry located on the North Wing nursing unit revealed the ice machine's dispenser contained a thick white build-up of white substance around the dispenser opening.

Observation on February 26, 2026, at 10:47 AM of the resident food pantry located on the Spruce nursing unit revealed the ice machine's condensation hose "DrainGap" fitting device (a component designed to create an air gap, which is an open space between the end of the drain hose and the floor drain that prevents contaminated water, sewage, or bacteria from flowing backward into equipment that produces ice) was in direct contact with the floor drain, eliminating the protective separation intended to prevent contamination. The floor drain and surrounding tiles were visibly covered with a wet black substance, and several floor tiles were broken and cracked. The pantry microwave contained an eight-inch rust-like area along the top left interior wall and two 1.5-inch rusted areas on the interior ceiling.

Observation on February 26, 2026, at 11:01 AM of the resident food pantry located on the Willow nursing unit revealed the ice machine's condensation hose "DrainGap" fitting device was in direct contact with the floor and not aligned with the floor drain, eliminating the protective separation intended to prevent contamination. Evidence of water damage was observed to six floor tiles surrounding the drain area. The "DrainGap" condensation hose end piece and surrounding floor tiles were visibly soiled with a black substance.

During an interview on February 26, 2026, at 1:45 PM the Nursing Home Administrator confirmed that the ice machines and microwave were not maintained in a sanitary manner.

28 Pa. Code 201.18 (e)(2.1) Management.

28 Pa. Code 211.6 (f) Dietary Services.

Plan of Correction - To be completed: 04/01/2026

F 0812
1. The ice machines have been cleaned of any debris by the maintenance staff. The ice machine on Willow has had the Drain Gap fitting device moved so it is not in direct contact with the floor. The hose and tiles have been cleaned. The microwave has been replaced.

2. The maintenance staff has completed a check of ice machines, microwaves, hoses, and tiles to verify proper sanitary conditions.

3. The maintenance staff will be educated by the Maintenance Director/Designee on the need of monitoring ice machines, microwaves, hoses, and tiles for sanitary conditions.

4. Audits will be completed weekly x 4, then monthly x 3 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:

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.

§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.

Observations:

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to afford a resident and their designated representative the right to participate in the development of the resident's plan of care for one resident out of 36 sampled residents (Resident 11).

Findings include:

A review of the facility policy titled "Care Planning-Resident Participation," last reviewed by the facility on January 6, 2026, revealed it is the facility policy to support the resident's right to be informed of and participate in their care planning and treatment (implementation of care). The policy indicates the facility will notify the resident and/or resident representative of the risks and benefits of proposed care, treatment, and treatment alternatives or options. The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care.

A clinical record review revealed Resident 11 was admitted to the facility on May 17, 2024, with diagnoses that include acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs).

A review of Resident 11's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 8, 2026, revealed that Resident 11 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact).

During an interview on February 24, 2026, at 12:02 PM Resident 11 explained that she would like to receive more therapy and restorative services (nursing based exercises to help maintain or improve strength and movement) to address her deficits related to ambulation. Resident 11 indicated that she has not addressed the concern with the facility.

A progress note dated February 25, 2026, at 1:42 PM indicated a care plan meeting was held on February 25, 2026, with the resident. No family present. The note indicated social services reviewed Resident 11's code status, diet, weights, meal consumption, transfer status, assistance with activities of daily living care, therapy status, and psychosocial needs.

During a follow-up interview on February 26, 2026, at 10:10 AM, Resident 11 had no knowledge of a care plan meeting and was not invited to participate in a care plan meeting on February 25, 2026. She indicated that she has not discussed her therapy status, activities of daily care, and/or preferences of daily care with facility staff. She indicated that she has not had the opportunity to discuss her preferences for more therapy and restorative services to address her deficits related to ambulation.

A clinical record review revealed no documented evidence the resident was notified that a care plan meeting was scheduled to occur on February 25, 2026. Also, a clinical record review revealed no documentation that Resident 11 was provided an opportunity to fully participate in establishing her expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.

During an interview on February 27, 2026, at approximately 10:30 AM, the nursing home administrator (NHA) confirmed there was no documented evidence that Resident 11 or Resident 11's representative was invited to participate in the resident's care plan development. The NHA was unable to provide documented evidence the interdisciplinary team and Resident 11 met and provided Resident 11 an opportunity to fully participate in establishing her expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. The NHA was unable to provide a list of facility staff that met on February 25, 2026, as part of Resident 11's care plan meeting. The facility failed to ensure a person-centered care planning process was completed by failing to invite or include Resident 11 in the development of her goals and frequency of services, resulting in the resident's concerns regarding services for ambulation not addressed.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c) Resident care policies.

28 Pa. Code 211.12(d)(3) Nursing services.

Plan of Correction - To be completed: 04/01/2026

F 0553
1. Resident 11 and their representative was invited to participate in the development of the resident's plan of care related to therapy and restorative services.

2. The Social Service Staff/designee shall complete an initial audit of Care Plans meetings scheduled within the last 7 days to verify that the residents/representative were invited to attend in the development of the resident's plan of care

3. The Social Services staff shall be educated by the Educator/designee on the importance of inviting residents /representatives to their care plan meetings for development of the resident's plan of care.

4. Random audits of care plan meetings shall be conducted by the Social Service director/ designee to assure that resident/representatives are invited to participate in the development of the resident's plan of care. Audits will be completed weekly x 4, then monthly x 3 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

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

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, resident observation, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set for one of 36 sampled residents (Resident 199).

Findings include:

A clinical record review revealed resident 199 was admitted to the facility on September 15, 2023, with a diagnosis of urinary incontinence (the loss of control over one's urine). A review of a significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 30, 2025, revealed that Resident 199 did not experience any limitation in range of motion (ROM) (referring to the full movement of a joint) in the upper extremities. MDS section GG-0115 (section related to functional abilities, the ability to perform tasks and activities necessary for daily living) indicated Resident 199 did not experience any limitation in moving one's shoulders, arms, elbows, wrist, hands, and fingers.

Clinical record review revealed an evaluation by occupational therapy (certification period August 4, 2025, to October 25, 2025) and indicated Resident 199 had limited ROM in the right and left upper extremities including shoulders, elbows, wrists, and fingers. The therapy evaluation identified Resident 199 had bilateral hand contractures (permanent tightening of muscles, tendons, ligaments, or skin, which severely impacts joint mobility and function). The therapy evaluation revealed Resident 199 had a mobility performance score of 0. The mobility function score ranges from 0-12, 0 indicated the lowest level of function.

Observation of Resident 199 while in bed, on February 24, 2026, at 10:45 AM revealed bilateral upper extremities (including elbows, wrists and fingers) with obvious joint deformities. The resident's elbows were observed in a fixed flexed position (permanently bent and unable to be straightened) held close to the chest. Both hands were observed in a closed, flexed position with the fingers tightly bent toward the palm. When asked, the resident was unable to open either hand or extend the arms. Dressings were observed in both hands and between the fingers. These observations were consistent with significant limitations in movement of the upper extremities (arms and hands). However, a review of the resident's Significant Change Minimum Data Set (MDS) assessment dated December 30, 2025, Section GG0115, Functional Abilities and Goals indicated the resident did not have limitations with movement of the upper extremities. The observed physical limitations and therapy evaluation did not correspond with the MDS coding indicating no limitation.

A review of the same significant change MDS dated December 30, 2025, Section GG0120. Mobility Device (addressing devices used to assist with mobility such as walking), revealed Resident 199 uses a walker for mobility and ambulation. This information was inconsistent with the coding in Section GG0170, Mobility (which documents how a resident performs movement activities such as rolling in bed, sitting, standing, and transferring). Section GG0170 indicated the resident was dependent (helpers perform all of the effort, the resident does none of the effort to complete the activity) for multiple mobility activities, including rolling from left to right, sitting to lying, sitting to standing, and transferring from the bed to a chair. The coding in Section GG0170 further indicated the resident was unable to walk or move independently. The documentation indicating the resident used a walker for ambulation did not correspond with the resident's documented dependence for mobility and inability to walk.

During an interview on February 25, 2026, at 1:45 PM, the Director of Nursing reviewed the above information and confirmed the MDS assessment data was inaccurate and did not accurately reflect Resident 199's limited upper extremity movement or the resident's mobility status.

28 Pa. Code 211.5(f)(iii) Medical records.

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

Plan of Correction - To be completed: 04/01/2026

F 0641
1. Section GG - Functional Abilities of MDS for resident 199 has been modified to accurately reflect resident's functional status.

2. The MDS coordinators/designee will review MDS completed within the last 7 days to assure Section GG - Functional Abilities accurately reflect resident's functional status.

3. The MDS Coordinators shall be educated by Regional MDS Manager on assuring Section GG - Functional Abilities accurately reflects resident's functional status.

4. The MDS Coordinators/designee will complete random audits of Section GG - Functional Abilities to assure it accurately reflects resident's functional status. Audits will be completed weekly x four weeks, then monthly X 3, then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on a review of pre-admission records, facility clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop a baseline care plan that documented interim, person-centered approaches to address the resident's identified fall risk for one of 36 sampled residents (Resident 14).

Findings include:

A review of the clinical record revealed Resident 14 was admitted to the facility on October 31, 2025, with diagnoses including chronic respiratory failure with hypoxia (lungs cannot deliver oxygen to the body). A review of Resident 14's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 6, 2025, revealed Resident 14 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; score between 0 and 7 indicate severe cognitive impairment).

A review of Resident 14's pre-admission medical records revealed the resident experienced two falls in the weeks prior to admission. Documentation indicated a fall occurred at home on October 12, 2025, at 2:15 AM, and another fall occurred at home on October 16, 2025, at 3:00 AM.

A review of the facility's Baseline Care Plan Policy, reviewed January 6, 2026, indicated the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. The policy explanation and compliance guidelines revealed that initial goals shall be established that reflect the resident's stated goals and objectives. The interventions shall be initiated that address the resident's current needs including any health and safety concerns to prevent decline or injury such as elopement, fall, or pressure injury risk as well as any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. The baseline care plan must be developed within 48 hours of the resident's admission.

A review of nursing documentation dated November 4, 2025, at 1:43 AM revealed Resident 14 was observed in the hallway without clothing on the lower half of the body. The documentation indicated the resident wandered into other residents' rooms and went through other residents' belongings. Nursing staff attempted to redirect the resident using snacks, drinks, and activities such as coloring and folding laundry. The documentation indicated the resident required one-to-one supervision (continuous monitoring by a staff member assigned to observe the resident at all times) and returned to bed at approximately 5:00 AM.

A review of nursing documentation dated November 8, 2025, at 7:00 AM revealed Resident 14 remained restless throughout the night. Documentation indicated that both non-medication interventions (such as activities, food, and providing a calm environment) and medication were not effective in reducing the resident's restlessness. The note indicated the resident required staff supervision for most of the night.

A review of the clinical record revealed Resident 14 experienced a fall without injury on November 8, 2025, at 7:45 AM. Nursing documentation indicated the resident was confused and looking for socks at the time of the fall. The note further indicated the resident was wearing properly fitting, non-skid socks. Interventions initiated after the fall included checks by staff every 15 minutes from 7:00 PM through 9:00 AM for 72 hours, an evaluation by therapy, and neurological checks (assessments performed by staff to monitor a resident after a fall such as level of consciousness, alertness and the ability to move) in accordance with facility policy.

A review of the baseline care plan initiated on October 31, 2025, indicated Resident 14 had safety risks, including falls, and documented the resident experienced multiple falls at home prior to admission. However, the baseline care plan lacked specific, resident-centered fall prevention interventions to reduce the resident's risk for falls during nighttime hours, despite documented falls occurring during nighttime hours prior to admission and observations of nighttime wandering and unsafe behaviors after admission.

During an interview on February 27, 2026, at 10:15 AM, the Director of Nursing confirmed the baseline care plan for Resident 14 did not include individualized fall prevention interventions consistent with the resident's identified nighttime behaviors and fall risk and was not consistent with the facility's baseline care plan policy.

28 Pa. Code 211.10 (c)(d) Resident care policies.

28 Pa Code 211.12 (d)(3)(5) Nursing services.

28 Pa. Code 211.5(f)(iii) Medical records.

Plan of Correction - To be completed: 04/01/2026

F 655
1. The facility cannot retroactively correct this issue. Resident 14 had no negative impact.

2. The DON/ designee reviewed Base Line Care Plans for residents admitted to the facility in the last 7 days to ensure base line care plans have person- centered approaches to address resident's risk for falls.

3. Unit Managers/ designee will be educated by the DON/Designee on the importance of assuring that base line care plans have person- centered approaches to address resident's risk for falls.

4. Random audits of baseline care plans will be done to assure care plans have resident- centered fall prevention measures to address resident's risk for falls. Audits will be done weekly x 4 then monthly x 3 months then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

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

§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 a review of clinical records, investigative documentation provided by the facility, select facility policy, manufacturer guidelines, and staff interview, it was determined the facility failed to ensure appropriate prevention and management of a pressure injury for one of 36 sampled residents (Resident 9).

Findings include:

Review of the facility's Pressure Injury Prevention and Management policy, reviewed January 6, 2026, revealed that the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Interventions could include, but are not limited to, redistribution of pressure, minimizing exposure to moisture, and providing appropriate, pressure-redistributing support surfaces.

Clinical record review revealed that Resident 9 had diagnoses including chronic kidney disease (a long-term medical condition in which the kidneys gradually lose the ability to filter waste and excess fluid from the blood) and a history of pressure injuries (damage to the skin and underlying tissue caused by prolonged pressure on the skin, most often over bony areas of the body). The resident also had an unstageable pressure ulcer (the wound is covered by dead tissue or scabbing that prevents healthcare staff from determining the full depth and severity of the wound until the tissue covering the wound is removed) on the coccyx (tailbone area located at the lower end of the spine).

A review of Resident 9's quarterly Minimum Data Set assessment, MDS, a federally mandated standardized assessment process conducted periodically to plan resident care dated January 10, 2026, revealed that Resident 9 was severely cognitively impaired with a BIMS score of 1, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information indicates a score of 0-7 indicates severe cognitive impairment). The MDS indicated the resident required staff assistance with mobility in bed and when transferring between bed and chair and had a Stage III pressure ulcer (a full thickness loss of skin where the underlying fat tissue may be visible and dead tissue may be present, although the depth of the wound can still be determined).

Investigative documentation provided by the facility dated December 28, 2025, at 8:00 PM revealed staff identified a pressure ulcer on Resident 9's coccyx that measured 1 centimeter by 0.5 centimeter. However, the investigation failed to document the depth of the wound and failed to determine the stage of the pressure ulcer, which is a clinical method used to classify the severity and depth of a pressure injury.

The investigation indicated the resident had a history of pressure injuries in the same location and that the previously healed area had reopened after healing on November 24, 2025. The facility identified potential contributing factors including immobility, incontinence (inability to control bowel or bladder function), and fragile skin. The investigative report included a staff statement indicating the resident was incontinent of bowel and bladder and that staff had attended to the resident two hours earlier. The report also indicated the resident spent time in both a chair and bed during the shift. However, the investigation did not include documentation describing the condition of the coccyx area prior to the identification of the pressure ulcer, did not describe the condition of the skin surrounding the wound, and did not determine whether preventative interventions identified in the resident's care plan were consistently implemented. The investigation also failed to determine whether a change in the resident's condition or care contributed to the reopening of the previously healed pressure injury.

A Braden Scale assessment (a standardized assessment tool used to determine a resident's risk for developing pressure injuries by evaluating factors such as mobility, activity level, moisture exposure, and nutritional status) had been completed for Resident 9 on December 28, 2025. The assessment indicated Resident 9 was at very high risk for developing pressure injuries due to being chairfast, having limited mobility, and being constantly moist due to urinary incontinence.

A review of the resident's care plan dated January 28, 2026, revealed interventions to prevent pressure injury development and promote wound healing. These interventions included staff repositioning the resident regularly while in bed and while seated in a chair to relieve pressure from vulnerable areas of the body. Staff task documentation for February 2026 indicated Resident 9 was to be repositioned every hour as part of pressure injury prevention measures.

However, a review of staff task documentation from February 1, 2026, through February 26, 2026, revealed the repositioning documentation was blank and lacked evidence that staff completed or documented the required repositioning interventions.

A review of Resident 9's February 2026 weight record revealed that on February 19, 2026, the resident weighed 99 pounds and on February 26, 2026, at 8:53 AM the resident weighed 98.5 pounds. The clinical record indicated the resident utilized a specialty therapeutic mattress identified as the Med-Aire Melody Alternating Pressure Low Air Loss Mattress to assist with pressure redistribution and wound healing to the resident's coccyx area.

Manufacturer guidelines for the Med-Aire Melody Alternating Pressure Low Air Loss Mattress indicated the mattress is designed to distribute a resident's body weight across the support surface in order to reduce pressure on vulnerable areas and promote healing of pressure injuries. The manufacturer instructions indicated the mattress must be set according to the resident's current weight in order to ensure proper pressure redistribution and therapeutic function for wound healing.

Observation of Resident 9's therapeutic mattress on February 26, 2026, at 9:15 AM and 2:15 PM, and again on February 27, 2026, at 10:20 AM, revealed the mattress weight setting was adjusted to 150 pounds. This setting was inconsistent with the resident's documented weight of 98.5 pounds. The mattress manufacturer indicated the system could accommodate residents weighing as little as 80 pounds.

A review of a wound assessment dated February 25, 2026, revealed the pressure ulcer on Resident 9's coccyx measured 2.0 cm by 1.0 cm by 0.20 cm and was identified as unstageable.

During an interview on February 27, 2026, at 9:15 AM, the Director of Nursing was unable to provide evidence that the facility conducted a thorough investigation to determine whether pressure injury prevention interventions were consistently implemented. The Director of Nursing was also unable to provide documentation demonstrating that the resident's repositioning schedule had been followed or that the incorrect therapeutic mattress weight setting had been identified and corrected to ensure appropriate pressure redistribution and promote healing of the pressure injury.

28 Pa. Code 211.10 (c) Resident care policies.

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

Plan of Correction - To be completed: 04/01/2026

F 0686
1. The facility cannot retroactively correct this issue related to resident 9.

2. An audit of residents with Pressure wounds in the last 7 days will be completed by the Unit Managers to ensure that appropriate wound healing interventions are in place.

3. Licensed nursing staff shall be educated by the DON/Designee on the importance of ensuring that residents with pressure wounds are turned per turning schedule and that appropriate therapeutic mattress is in place to promote wound healing.

4. Random observational audits of residents with pressure wounds will be conducted by the Unit Managers/designee to ensure that residents are turned per turning schedule and that appropriate therapeutic mattress is in place.

5. Audits will be completed weekly x 4, then monthly x 3 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 36 residents sampled (Resident 13).

Findings include:

A review of the facility policy titled "Restorative Nursing Program," last reviewed by the facility on January 6, 2026, revealed it is the policy of the facility to provide maintenance services (ongoing nursing support intended to preserve a resident's current physical abilities and prevent decline) and restorative services (structured nursing interventions designed to help a resident regain or improve functional abilities such as walking, transferring, or performing daily activities) designed to maintain or improve a resident's abilities to the highest practicable level. The policy indicates that residents, as identified during the comprehensive assessment process, will receive services from restorative aides (trained nursing assistants who provide restorative maintenance care under the supervision of licensed nursing staff) when they are assessed to have a need for restorative nursing services.

A clinical record review revealed Resident 13 was admitted to the facility on March 18, 2025, with diagnoses that include multiple sclerosis (a chronic autoimmune disease in which the body's immune system attacks the protective covering of nerves in the brain and spinal cord, which can cause weakness, problems with movement, balance, and coordination).

A review of Resident 13's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 1, 2026, revealed that Resident 13 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact).

An occupational therapy discharge summary dated November 25, 2025, revealed discharge recommendations for Resident 13 to have a restorative range of motion program established, which includes bilateral upper extremities active range of motion (AROM, movement of a joint performed by the resident using their own muscle strength to move the body part through its normal range of movement) through all planes as tolerated, two sets of 10 repetitions daily to improve range of motion and maintain strength and joint integrity.

A physical therapy discharge summary dated November 26, 2025, revealed discharge recommendations for Resident 13 to have a restorative nursing program, which includes bilateral lower extremity active range of motion and passive range of motion (PROM, movement of a joint performed by another person, such as nursing staff, who moves the resident's body part through its normal range of movement when the resident is unable to move it independently), manual stretches for improved range of motion, strength for bilateral lower extremities, and reducing the resident's risk for contractures.

A review of the resident's care plan revealed that Resident 13 required a nursing maintenance program initiated on August 28, 2025. Interventions implemented for Resident 13 were to maintain or improve the present level of functioning include discussing nursing maintenance appropriateness and progress in interdisciplinary department meetings and active range of motion upper and lower body exercises daily.

During an interview on February 24, at 11:36 AM, Resident 13 indicated that she is not receiving any therapy or restorative nursing services and is not encouraged or offered exercise daily. Resident 12 confirmed that she has a problem with her upper and lower body range of motion (ROM, the full, measurable distance and direction a joint or body part can move, ranging from bending to straightening).During an interview on February 24, at 11:40 AM, Resident 13's representative indicated that she was concerned the facility was not consistently implementing range of motion exercises with the resident.

A review of the documentation survey report for January 28, 2026, through February 25, 2026, revealed Resident 13 refused or was not applicable for bilateral upper extremity active range of motion exercises on 17 occasions during the 30-day period.

A review of the documentation survey report for January 28, 2026, through February 25, 2026, revealed Resident 13 refused or was not applicable for bilateral lower extremity active range of motion exercises on 17 occasions during the 30-day period.

A review of the documentation survey report dated February 25, 2026, revealed that Resident 13 actively participates in bilateral lower and upper active range of motion exercises with Employee 1, Nurse Aide (NA). The documentation indicated Resident 13 completed 30 repetitions and spent 15 minutes completing the upper body exercises. Also, the documentation indicated Resident 13 completed 30 repetitions and spent 15 minutes completing the lower-body exercise.

During an interview on February 26, 2026, at 10:02 AM, Resident 13 indicated that she did not receive or was offered 15 minutes of active upper body range of motion exercises or lower body range of motion exercises yesterday. Resident 13 reiterated she is not receiving any therapy or restorative nursing services and is not encouraged or offered exercise daily. Also, the resident confirmed that she is not refusing and did not refuse participation in these activities over the last 30 days.

During an interview on February 26, 2026, at 10:50 AM, Employee 1, Nurse Aide (NA), confirmed that she documented Resident 13 received 15 minutes of active upper body range of motion exercises and lower body range of motion exercises on February 25, 2026. Employee 1, NA, indicated that the range of motion exercises occur when the resident is assisted with activities of daily life. Employee 1, NA, could not confirm that Resident 13 completed 30 repetitions and spent 15 minutes completing the lower body exercises and completed 30 repetitions and spent 15 minutes completing the upper body exercises.

During an interview on February 26, 2026, at 12:05 PM, the above information was reviewed with the director of nursing (DON). The DON was unable to explain why the documentation survey report indicated that Resident 13 refused or was not applicable for bilateral lower and upper extremity active range of motion exercises on 17 occasions during the 30-day period. The facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for Resident 13.

28 Pa. Code: 211.5(f)(ii) Medical records.

28 Pa. Code: 211.10(c) Resident care policies.

28 Pa Code 211.12(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/01/2026

F 0688
1. The facility cannot retroactively correct this issue. Resident 13 had no negative impact E1 NA was educated on providing restorative nursing services as per plan of care.

2. A review of residents with restorative programs related to ROM will be conducted by DON/designee to ensure restorative nursing services are provided as per plan of care to maintain mobility to the extent possible

3. The Restorative aide and nursing staff will be educated by the DON/Designee on the importance of providing restorative nursing services as per plan of care to maintain mobility to the extent possible.

4. Random audits of residents on ROM restorative programs will be conducted by the Unit Managers/designee to ensure restorative nursing services are provided per plan of care to maintain mobility to the extent possible. Plan of care will be revised as needed. Audits will be completed weekly x 4, then monthly x 3 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 36 residents sampled (Resident 141).

Findings include:

A review of Resident 141's clinical record revealed the resident was admitted to the facility on November 26, 2025, with diagnoses to include mild neurocognitive disorder with behavioral disturbance (a slight, noticeable decline in cognitive abilities that does not significantly interfere with daily independence and is accompanied by agitation, irritability or mood changes) and cerebral infarction (stroke).

A nursing progress note dated January 20, 2026, indicated staff notified the physician of Resident 141's increased confusion and incontinence (the inability to control bladder or bowel function). The physician ordered STAT (immediate) laboratory testing, including a complete blood count (CBC, a blood test that measures the number and types of blood cells and can help identify infection or inflammation), a basic metabolic panel (BMP, a blood test that measures electrolytes, kidney function, and blood sugar levels), a urinalysis (UA, a laboratory test that examines the appearance and chemical composition of urine to detect signs of infection or other medical conditions), and a urine culture and sensitivity test (C&;S, a laboratory test that attempts to grow bacteria from a urine specimen to determine whether bacteria are present and, if so, which antibiotics would effectively treat the bacteria).

A physician's order dated January 21, 2026, directed staff to administer Ceftriaxone Sodium Injection (a powerful, long-acting antibiotic used to treat severe bacterial infections). The order instructed staff to administer 1 gram intramuscularly (injection of medication into a large muscle to allow the medication to be absorbed into the bloodstream) once daily for three days.

A laboratory report dated January 21, 2026, indicated the urine culture showed no significant growth, meaning the urine specimen did not contain enough bacteria to indicate an active urinary tract infection.

Review of Resident 141's January 2026 Medication Administration Record (MAR, the clinical document used by staff to record medications administered to a resident) revealed staff administered one dose of Ceftriaxone on January 21, 2026, despite the urine culture showing no significant bacterial growth. The physician discontinued the Ceftriaxone order on January 22, 2026.

A physician's order dated February 19, 2026, directing staff to obtain another urinalysis and urine culture and sensitivity test. An additional order dated February 20, 2026, directed staff to administer Ceftriaxone Sodium Injection 1000 milligrams intramuscularly once daily for a suspected urinary tract infection (UTI) followed by 500 milligrams intramuscularly on the second day and 500 milligrams intramuscularly on the third day.

A laboratory report dated February 20, 2026, indicated the urine specimen showed multiple flora suggesting contamination (the presence of several different types of bacteria that likely entered the specimen during collection, which means the test result may not accurately represent bacteria present in the bladder) or colonization (bacteria present in or on the body without causing illness, symptoms, or tissue damage). The report recommended repeating the test if symptoms worsened.

Review of the February 2026 MAR revealed staff administered Ceftriaxone on February 20, 2026, and again on February 21, 2026.

Review of physician's orders indicated the medication was discontinued on February 20, 2026; however, staff administered an additional dose on February 21, 2026.

During an interview on February 27, 2026, at 10:45 AM, the Infection Preventionist (IP) confirmed the resident's symptoms did not meet the McGeer Criteria (a standardized surveillance guideline used in long term care facilities to determine whether a resident has a true, symptomatic infection requiring treatment). The IP explained that the criteria help distinguish a true urinary tract infection from asymptomatic bacteriuria (the presence of bacteria in the urine without symptoms of infection). The IP acknowledged that the administration of Ceftriaxone was not clinically indicated and confirmed the resident received unnecessary antibiotic therapy that was not consistent with evidence-based infection control practices or antimicrobial stewardship principles (programs designed to ensure antibiotics are used only when medically necessary to reduce antibiotic resistance and prevent avoidable medication exposure).

28 Pa. Code 211.2(d)(3)(5) Medical Director.

28 Pa. Code 211.12(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/01/2026

F 0757
1. The facility cannot retroactively correct this issue Resident 141 had no negative impact

2. The ICP/Designee will conduct a review of residents who are on antibiotics in the last 7 days to ensure that residents do not receive unnecessary antibiotics and evidence based McGeer Criteria is utilized while reviewing infection.

3. The Licensed nurses will be educated by the DON/designee on the importance of avoiding antibiotic resistance/unnecessary antibiotics by following McGeer Criteria while reviewing infections.

4. Audits will be conducted with residents on antibiotics to ensure that residents do not receive unnecessary antibiotics and evidence based McGeer Criteria is utilized while reviewing infections. Audits will be conducted weekly x 4, then monthly x 3 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.

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