Health inspection·March 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Page 1 of 3 395680 395680 03/16/2023 Willow Brook Rehabilitation and Healthcare Center 120 Trexler Avenue Kutztown, PA 19530

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. 395680 Page 2 of 3 395680 03/16/2023 Willow Brook Rehabilitation and Healthcare Center 120 Trexler Avenue Kutztown, PA 19530

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. 395680 Page 3 of 3