**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to provide maintenance services to ensure safe water temperatures on one of two nursing units. (Willowbrooke Court) Findings include: Observation on March 22, 2023, at 10:00 a.m., on the Willowbrooke Court nursing unit revealed the following elevated water temperatures in areas accessible to residents: Public restroom across from the Administrator's office: 118.9 degrees Fahrenheit (°F). Resident room [ROOM NUMBER] bathroom sink: 120.2 °F. Resident shower room sink (spa): 120.3 °F. Willow dining room sink: 120.2 °F. Resident room [ROOM NUMBER] bathroom sink: 115.8 °F. Willow Gardens laundry room sink: 116.4 °F. In an interview during that time, Employee 1 (maintenance staff) confirmed that water temperatures in areas accessible to residents should be 110 °F or lower. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 207.2(a) Administrator's responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and a review of incident reports, it was determined that the facility failed to implement recommended fall interventions for one of six sampled residents at risk for falls. (Resident 73) Findings include: Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], and had diagnoses that included dementia, history of falling, and rhabdomyolysis (breakdown of skeletal muscle due to muscle injury). Review of the Minimum Data Set assessment, dated March 14, 2022, revealed the resident was cognitively impaired and required extensive assistance from staff for bed mobility and toileting. Review of the care plan revealed the resident was at risk for falls due to impaired balance, weakness, and dementia. Review of incident reports revealed that on January 14, 2022, Resident 73 fell from his recliner and the interdisciplinary team recommended an Occupational Therapy (OT) evaluation. On January 15, 2022, the resident again fell from his recliner. The interdisciplinary team stated to continue OT, although therapy services had not been started. The resident was not evaluated by the occupational therapist until January 24, 2022, when he experienced an additional (third) fall from the recliner. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility menu review, observation, and staff interview, it was determined that the facility failed to provide therapeutic diets as ordered by the physician for two of 19 sampled residents. (Resident 19, 30) Findings include: Review of the facility lunch menu revealed that residents who were ordered a regular mechanical soft dysphagia diet were to receive items which included a crustless sloppy joe sandwich on March 29, 2022, and a ground turkey burger, chopped herbed green beans, and crustless white bread on March 31, 2022. Clinical record review revealed that Resident 19 had diagnoses that included dementia and oropharyngeal dysphagia (difficulty swallowing) and had a physician's order to receive a regular diet with mechanical soft dysphagia texture (may have Cheerios). Observation during lunch on March 31, 2022, at 12:17 p.m., revealed that the resident received pureed texture turkey and green beans. In addition, the resident was not offered crustless white bread. Clinical record review revealed that Resident 30 had diagnoses that included dementia and oropharyngeal dysphagia and had a physician's order to receive a regular diet with mechanical soft dysphagia texture (minced/moist). Observation during lunch on March 29, 2022, at 12:08 p.m. revealed that the resident received pureed texture sloppy joe sandwich. Observation during lunch on March 31, 2022, revealed that the resident received pureed texture turkey and green beans. In addition, the resident was not offered crustless white bread. Observation of the food preparation area revealed that mechanical soft dysphagia texture foods were not available. During an interview on March 31, 2021, at 12:21 p.m., dietary aide (DA2) was plating the food for residents and confirmed that residents with physicians' orders for a mechanical soft dysphagia diet were routinely served pureed consistency items and that ground items were not available. 28 Pa. Code 211.6(b)(c) Dietary services. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner during tray line service in one of two dining rooms. (Willowbrooke Court Dining Room) Findings include: Review of the policy entitled, Single Use Glove Usage, dated January 26, 2022, revealed that gloves should only be used for one task, such as ready to eat foods, and then discarded. Observation of tray line service on March 30, 2022, at 12:05 p.m. in the Willowbrooke Court Dining Room revealed the Nutrition Services Manager serving unwrapped food from the steam table, leaving the service line to rinse a knife in the sink, returning to the tray line, and serving unwrapped food without changing her gloves. Observation of tray line service on March 31, 2022, revealed dietary aide (DA1) serving unwrapped food from the steam table, leaving the tray line and opening cabinets and the gate to the steam table area to obtain items. DA1 returned to tray line and continued serving unwrapped food after touching the cabinet handle and steam table gate without changing her gloves. In an interview on March 31, 2022, at 12:02 p.m., the Director of Culinary Services confirmed staff should change their gloves whenever they change tasks. 28 Pa. Code 211.6(c)(f) Dietary services.