Willowcrest

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Observations conducted on December 29, 2025, at 9:56 a.m. with the Food Service Director (FSD), Employee E4, and Chef, Employee E5, in the main kitchen revealed food items were improperly labeled, undated, uncovered, or stored in a manner that could lead to contamination. Observations in the main refrigerator revealed blue cheese (2lbs- pounds) that was undated and additional 3 lbs. without a use-by-date; 3lbs of Monterey [NAME] cheese with no date; 5 lbs. [NAME] cheese with use-by dates of 12/12 and 12/30; 5lbs [NAME] cheese that was undated; mild cheddar slices that were opened, exposed, and undated; and Swiss cheese that was opened and undated. Continued observation revealed three 4-8 lb. bags of beef vegetable soup without thaw or pull dates,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understood for one of three closed records reviewed (Resident R50).Findings include: Review of Resident R50's medical records revealed that on December 11, 2025, the resident was admitted to the hospital for shortness of breath. Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator, Employee E1 on January 5, 2026, at 1:00 p.m. confirmed this finding. Continued interview with the facility administrator, Employee E1 on January 5, 2026, at 1:05 p.m. confirmed the above-mentioned findings and stated that it is not facility practice providing the residents and/or their representative with a written notice for transfers. 28 Pa. Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to review and revise a resident care plan with new interventions status prior and post a fall incident for one of 12 residents reviewed (Resident R24).Findings include:Review of facility policy titled Resident Assessment and Plan of Care revised July 2018 states the process of systematically reviewing a resident's physical functional mental and psychological status to identify strengths and weaknesses for which the interdisciplinary team can develop a plan of care for each resident. Review of the November 20, 2025, therapy note assessed Resident R24 with impairments and limitations with the resident's ADL's (activities of daily living), bed mobility, cognitive, decreased knowledge of condition, decreased knowledge of precautions, and safety awareness. Therapist noted that the resident tended to favor the resident's left side (weak side). To incorporate bed mobility and safe positioning in bed, the nursing staff were notified to use a wedge pillow with dycem…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility documentation and interview with staff, it was determined that the facility failed to ensure an incontinent resident who was unable to carry out activities of daily living received the appropriate services with toileting for one of 12 resident records reviewed (Resident R24).Findings include: Review of Resident R24's occupational therapy (OT) assessment notes dated November 20, 2025, revealed the resident was admitted to the facility on [DATE], with a history of traumatic intracranial hemorrhage (bleeding in the brain), right Middle Cerebral Artery (aka MCA stroke) in October 2025 which left the resident with left residual weakness and left sided body pain. The therapist assessment indicated the resident's impairments included impaired safety/judgment, and functional communication impairments, that included Dysarthria, (speech disorder leading to slurred or low speech) and aphasia (a language disorder caused by brain damage). The same assessment noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure care and treatment were provided in accordance with physician orders for one of 12 residents reviewed. (Resident R3)Findings Include: Review of resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including fractures, foot drop (inability lifting the front part of the foot). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of nine, indicating moderate cognitive impairment. Continued review of Resident R3's clinical records revealed a physician order dated December 1, 2025, for multipodus boots to left foot drop (orthopedic positioning boots used to protect and properly align the foot and ankle). The physician order failed to indicate parameters for use, including duration, timing, and conditions for use of the mulitpodus boots. Interview conducted on December 30, 2025, at 11:20 a.m. with registered Nurse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, review of clinical records, and staff interview, it was revealed that the facility failed to assess and implement interventions to ensure acceptable parameters of nutritional status for one of 2 residents reviewed for nutrition (Resident R16). Findings include: Review of facility policy, Height and Weight Protocol dated January 1, 2025, revealed that upon admission, residents' weight and height will be recorded and residents with a weekly weight gain or weight loss of five pounds will be re-weighed. Review of Resident R16's clinical records revealed that on December 12, 2025, the resident's admission weight was documented as 94 pounds. A follow-up interview conducted on January 2, 2026, at 11:20 a.m. with Registered Dietitian (RD), Employee E3, revealed that the admission weight of 94 pounds was not transcribed into the system and was therefore not referenced by the nutrition services team when assessing Resident R16's weight changes. Continued record review revealed that on December 17, 2025, Resident R16's weight was documented as 104.7 pounds,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident group interview, and staff interview, it was determined that the facility failed to ensure that grievance forms were available and accessible to residents and failed to provide an opportunity for anonymous grievances to be submitted for three of three residents reviewed. (Reisdents R76, R80 and R125) Findings include: Review of facility policy titled Grievance Policy for Residents and Resident Representatives, dated 2017, revealed each resident has the right to voice grievances and recommend changes for improvement to staff, administration, or outside representative of his/her choice, without discrimination or reprisal. Also, a prominent posting will be located in the lobby and 3rd floor with Grievance Official contact information. A resident group interview was conducted on January 28, 2025 at 11:04 a.m. with Residents R76, R80, R125, who were alert and orientated, and reported that they did not know how to file grievances anonymously and do not know where the grievance forms are located. Observation on the 3rd floor revealed no grievance forms or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Respiratory Precautions for one resident on respiratory precaution of seven residents reviewed (Resident R122). Findings include: Review of facility policy on Enhance Respiratory Precaution reveled that under section PURPOSE: To prevent transmission of emerging or highly pathogenic infections spread by means of respiratory route. Under section POLICY: Any patient known or suspected to have an infection with an emerging or highly pathogenic organism that may be transmitted by means of the respiratory route shall be placed on Enhanced Respiratory Precaution. Section GENERAL SCOPE OF PRACTICE: #D. Personal Protective Equipment (PPE); Prior to entering the room, staff shall perform hand hygiene and then don appropriate respiratory protection (N95- a respiratory protective device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 3 residents reviewed (Residents R1). Findings include: Review of Resident R1's clinical record indicated admission date January 29, 2024, and had diagnoses including ventricular tachcardi (is a type of abnormal heart rhythm (arrhythmia) characterized by a rapid heartbeat originating from the heart's lower chambers, the ventricles), coronary artery disease (cad) (condition characterized by the narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart muscle), heart failure, atrial fibrillation, (which is the most common type of heart arrhythmia). Review of physician orders indicated that Resident R1 was prescribed Melatonin 9 milligrams (mg) one a day in the evening on January 29, 2024 Interview conducted on February 8, 2024, at 10:12 a.m. with License nurse, unit manager, Employee E5 confirmed that the facility policy for medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.