Glen Brook Rehabilitation And Healthcare Center
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER in BERWICK, PA — inspection on February 27, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
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 [DATE], 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 [DATE], 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.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
for Resident 14 did not include individualized fall prevention interventions consistent with the
(d)(3)(5) Nursing services. 28 Pa.
Code 211.5(f)(iii) Medical records.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
During an interview on February 27, 2026, at 9:00 AM, the Director of Nursing reviewed the above findings and confirmed that nursing staff failed to follow the physician's order by administering the medication outside the ordered parameters. A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include right femur (thigh bone) fracture (broken bone), lumbar disc degeneration (spinal discs in lower back lose water, elasticity and height, often causing chronic pain and stiffness), and muscle weakness. A review of the physician's order dated October 20, 2025, directed staff to provide a lateral support to the right side of the resident's wheelchair to promote proper positioning and stability. A lateral support is a padded L-shaped positioning device attached to the wheelchair to provide lateral stability, help maintain a neutral upright sitting position, and improve posture by supporting the torso. It prevents side-to-side leaning and fatigue.
Observation on February 24, 2026, at 12:30 PM revealed Resident 4 seated in her wheelchair at the entrance to her room.
She was leaning significantly over the right side of her wheelchair.
The ordered lateral support was not attached to the wheelchair.
The device was observed in a laundry basket on a chair in the resident's room. A second observation on February 26, 2026, at 1:10 PM, conducted in the presence of Employee 2 (Licensed Practical Nurse), confirmed the physician ordered lateral support was not in place on the resident's wheelchair.
These findings demonstrated the facility failed to ensure nursing services were provided in accordance with physician orders and professional standards of practice. 28 Pa.
Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa.
Code 211.12 (c)(d)(1)(3)(5) Nursing services.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
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 [DATE], 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.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
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.
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603
Director 28 Pa.
Code 211.12(d)(3)(5) Nursing services
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 [NAME] 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
395421 02/27/2026
Glen Brook Rehabilitation and Healthcare Center 801 East 16th Street Berwick, PA 18603