Willow Brook Rehabilitation And Healthcare Center
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER in KUTZTOWN, PA — inspection on March 27, 2026.
Found 4 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
Review of Resident 14's medication administration records (MAR) for February and March 2026, revealed that staff had noted Resident 14 was out of the facility six times in February and 11 times in March, and the medication was not administered.
Clinical record review revealed that Resident 14 was at dialysis at those times.
There was no evidence that staff notified the physician of the missed doses or that the facility addressed the resident's medication administration schedule to prevent missed doses on dialysis days.
Clinical record review revealed that Resident 22 had diagnoses that included diabetes and chronic kidney disease.
Physician's orders dated January 18, 2026, and February 3, 2026, directed staff to administer eight units of a diabetic medication NovoLog (insulin aspart) subcutaneously (under the skin) at 7:00 a.m., 11:30 a.m., and 4:30 p.m., 27 units of insulin glargine subcutaneously at 10:00 a.m., and 16 units of a diabetic medication insulin glargine subcutaneously at 9:00 p.m., every day.
Staff were not to administer the medication if the resident's blood sugar was less than 120 milligrams per deciliter (mg/dL).
Review of Resident 22's February and March 2026 MAR revealed that staff administered the insulin glargine one time in February and three times in March when the resident's blood sugar was less than 120 mg/dL.
Further review of Resident 22's March 2026 MAR revealed that staff administered the insulin aspart two times in March when the blood sugar was less than 120 mg/dL.
Clinical record review revealed that Resident 70 had diagnoses that included hypotension. A physician's order dated February 28, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension.
Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg).
Review of Resident 70's February and March 2026 MARs revealed that staff administered the medication one time in February and seven times in March when the resident's SBP was greater than 120 mm/Hg.
In an interview on March 27, 2026, at 10:36 a.m., the Director of Nursing (DON) stated that if a medication could not be administered, the nurse was to contact the physician of the missing dose by the next day.
The DON further confirmed that there was no documented evidence that nursing staff notified the physician that the midodrine was not administered to Resident 14 due to the resident being at dialysis in February and March and that the nurses were to have held the insulin when Resident 22's blood sugar was below 120 mg/dL.
The DON also confirmed at that time that Resident 70 should not have received midodrine when the SBP was greater than 120 mm/Hg. 28 Pa.
Code 211.12(d)(1)(5) Nursing services.
395680 03/27/2026
Willow Brook Rehabilitation and Healthcare Center 120 Trexler Avenue Kutztown, PA 19530
that weekly dressing changes are properly ordered by the physician and completed.3.
Any residents admitted with a PICC line will be reviewed to assure that physician's orders include weekly dressing changes. RN Supervisor will ensure that orders are in place.4.
The Director of Nursing (DON) reviewed the policy and procedures for PICC and wound management policy to ensure professional standards are provided.5.
Staff educator/designee will educate licensed nursing staff on the policy and procedure related to care and management of a midline peripheral venous access device and wounds.6.
Staff educator/designee will educate licensed nursing staff on obtaining physician's orders when any new skin alteration is identified.7.
All staff scheduled for the evening shift (3:00 p.m. to 11:00 p.m.) on March 25, 2026, will be educated with 100 percent of staff on that shift educated by March 25, 2026. 8.
All staff scheduled for the night shift (11:00 p.m. to 7:00 a.m.) on March 25, 2026, will be educated with 100 percent of staff on that shift educated by March 25, 2026. 9.
All other licensed staff and providers will be educated via telephone education with 100 percent of all staff educated by March 25, 2026.10.
Licensed staff who cannot be reached by March 25, 2026, will be removed from the schedule pending completion of education.11. DON/Designee will review new admissions/re-admissions within 72 hours to ensure all physicians' orders are verified.
This will be audited weekly for four weeks then monthly for four months.
Results will be reported in Quality Assurance and Performance Improvement (QAPI).12. DON/Designee will do random audit of residents with PICC/wounds daily for five days to ensure dressing changes are completed as ordered followed by weekly audits for four weeks, then monthly for four months.
Results will be reported to QAPI.
The survey team validated that Immediate Jeopardy was removed on March 25, 2026, at 6:40 p.m., through observation, review of the facility training, and staff interviews following the facility's implementation of the plan for removal of the Immediate Jeopardy.
The deficient practice remained at scope/severity D (isolated with potential for more than minimal harm) following the removal of the Immediate Jeopardy. 28 Pa.
Code 211.10(c)(d) Resident care policies 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395680 03/27/2026
Willow Brook Rehabilitation and Healthcare Center 120 Trexler Avenue Kutztown, PA 19530
Review of the facility policy entitled, Controlled Substance Administration and Accountability, last reviewed February 26, 2026, revealed that two licensed nurses were to account for all controlled substances at the end of each shift for areas without automated dispensing systems.
Review of the controlled substance logs for January, February, and March 2026, for the Unit I and Unit II medication carts (without automated dispensing systems) revealed the following: There was no documented evidence that the controlled substances were counted after every shift on 15 of 31 days from January 1 through 31, 2026.
There was no documented evidence that the controlled substances were counted after every shift on 14 of 28 days from February 1 through 28, 2026.
There was no documented evidence that the controlled substances were counted after every shift on 11 of 24 days from March 1 through 24, 2026.
In an interview on March 25, 2026, at 9:15 a.m., the Director of Nursing confirmed that the nurse coming on duty and the nurse going off duty were to sign that specific cart's Shift Count Log to verify that they counted the narcotics at the end of the shift and that there were no discrepancies with the count. In an interview on March 27, 2026, at 10:38 a.m., the Director of Nursing confirmed that there was no evidence that the controlled substances were counted and signed off on the identified dates as per facility policy and should have been. 28 Pa.
Code 211.9(j.1)(5) Pharmacy services. 28 Pa.
Code 211.12(d)(1)(5) Nursing services.
395680 03/27/2026
Willow Brook Rehabilitation and Healthcare Center 120 Trexler Avenue Kutztown, PA 19530
sampled residents. (Resident 19)Findings include:
Review of the facility policy entitled,
medications were to be administered in accordance with professional standards of practice and gloves were to be applied prior to administration of the eye drops. On March 25, 2026, at 8:50 a.m., Licensed Practical Nurse (LPN) 1 was observed administering medications to Resident 19. LPN 1 administered a medicated eye drop used to treat eye inflammation, swelling, and redness caused by surgery, injury, or allergies (prednisolone 1%) and a medicated eye drop used to treat bacterial eye infections (ofloxacin 0.3%) to the eyes of the resident with her ungloved hands. In an interview on March 26, 2026, at 9:55 a.m., the Director of Nursing confirmed that the nurse should have been wearing gloves to administer medications to the eyes. 28 Pa.
Code 211.10(d) Resident care policies. 28 Pa.
Code 211.12(d)(1)(5) Nursing services.