Inspection Reports for
The Willows of Living Branches
2343 BETHLEHEM PIKE,, HATFIELD, PA, 19440
Back to Facility Profile19 Reports
Inspection Report — Mar 9, 2026
Renewal
Date: Mar 9, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility license to verify compliance and the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included staff under 18 performing unsupervised personal care tasks, lack of required annual fire safety training for a staff person, fire drills conducted on the same weekday, and incomplete resident record content regarding photographs.
Citations (4)
54b Staff Under 18 Years: A direct care staff person aged 16 or 17 performed incontinence care, bathing, or dressing of residents without supervision on 2/27/2026 and 2/28/2026.
65g Annual Training Content: A staff person did not receive fire safety training completed by a fire safety expert or trained staff during the 2025 training year.
132g Fire Drills Days/Times: Fire drills conducted in May, June, and July were all held on Wednesdays, showing a pattern.
252 Record Content: Resident 1's record did not include a photograph that is no more than 2 years old.
Report Facts
Residents Served: 52
Current Hospice Residents: 1
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 3
Inspection Report — Apr 17, 2025
Monitoring
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a monitoring visit to the facility on 04/17/2025 to assess compliance with licensing requirements.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 45
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 83
Waking Staff: 62
Residents Age 60 or Older: 45
Residents with Mobility Need: 38
Notice — Apr 18, 2024
Date: Apr 18, 2024
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff educational qualifications has been granted.
Findings
The waiver allows specified direct care staff to serve without a high school diploma or GED based on equivalent foreign education credentials. The waiver is subject to conditions including documentation retention and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 11, 2024
Renewal
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of THE WILLOWS OF LIVING BRANCHES facility on 01/11/2024.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies related to record confidentiality, sanitary conditions, medication administration, prescription currency, storage procedures, and documentation of medication administration times were identified and addressed with corrective actions.
Citations (6)
The narcotics logbook was unlocked, unattended, and accessible on the medication cart near the dining hall.
Staff Person A used bare, ungloved fingers to administer medication to residents and failed to sanitize hands between administrations.
Staff Person B administered medication incorrectly by using a standing order and failed to follow proper medication administration procedures.
Discontinued earwax removal drops were found in the medication cart despite being discontinued months earlier.
Discrepancy in narcotics pill count: actual count was 39 but log documented 40 with no explanation.
Medication administration record for Resident 5 did not include initials of staff who administered medication as required.
Report Facts
Residents Served: 52
Current Hospice Residents: 2
Residents Diagnosed with Mental Illness: 32
Residents Aged 60 or Older: 52
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Aug 9, 2022
Renewal
Date: Aug 9, 2022
Visit Reason
The inspection was conducted as a renewal inspection of THE WILLOWS OF LIVING BRANCHES facility on 08/09/2022.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, incomplete staff orientation training, uncovered trash receptacles, unlabeled and undated food items, resident education gaps on medication refusal rights, incomplete preadmission screening forms, delayed resident assessments, and improper refrigerator temperatures. Plans of correction were accepted and implemented with specified completion dates.
Citations (9)
The resident-home contract for resident #1 was not signed by the resident.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Staff person A did not complete training on the emergency medical plan within 40 scheduled work hours.
Two uncovered, unattended trash cans were found in the kitchen.
Multiple food items in kitchen refrigerators, freezer, and dry storage were not labeled or dated.
Resident #1 was not educated on the right to question or refuse medication if a medication error is suspected.
Resident #1’s preadmission screening form did not include a determination that the resident's needs can be met by the home.
Resident #2’s initial assessment was not completed within 15 days of admission.
The temperature in the kitchen reach-in service refrigerator was 48.7°F, exceeding the required maximum of 40°F.
Report Facts
Residents Served: 42
Total Daily Staff: 44
Waking Staff: 33
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 25
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 2
Notice — Jul 21, 2021
Date: Jul 21, 2021
Visit Reason
The document serves as a renewal notification for the operation of The Willows of Living Branches Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The document confirms issuance of a regular license following the renewal application and states that the Department will conduct an inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jul 8, 2021
Renewal
Date: Jul 8, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for THE WILLOWS OF LIVING BRANCHES.
Findings
The inspection identified multiple deficiencies including failure to post the current license, untimely incident reporting, lack of influenza posters, delays in resident refund processing, missing emergency telephone numbers, staff unaware of first aid kit location, improper freezer temperature, lint accumulation in dryer, and obstructed egress routes. Plans of correction were submitted and accepted with completion dates ranging from July to November 2021, and all corrections were documented as implemented by October 29, 2022.
Citations (9)
The home's current license was not posted in a conspicuous and public place.
Incident reports were not dated or reported to the Department within 24 hours as required.
The home did not have an influenza poster posted anywhere as required by the Influenza Awareness Act.
Refund checks for discharged residents were not sent within the required 30-day timeframe.
Emergency telephone numbers were not posted on or by the telephone located in room 13.
Staff person did not know the location of the first aid kit.
The temperature in the freezer was 8 degrees Fahrenheit, above the required 0°F or below.
There was an approximate 2 inch accumulation of lint in the lint trap of the 2nd floor laundry dryer.
A welded galvanized steel chain and plants/shrubs were obstructing the exit to the staircase on the second floor.
Report Facts
Residents Served: 34
Current Hospice Residents: 1
Total Daily Staff: 34
Waking Staff: 26
Freezer Temperature: 8
Lint Accumulation: 2
Notice — Dec 2, 2020
Date: Dec 2, 2020
Visit Reason
The document grants a waiver to The Willows of Living Branches for the requirement that a personal care home administrator complete a Department-approved orientation program, due to the program's unavailability.
Findings
The waiver is granted with conditions including that the administrator must attend the orientation within 15 days of its availability and that documentation of training and qualifications be maintained and available upon request.
Inspection Report — Jan 6, 2020
Renewal
Date: Jan 6, 2020
Visit Reason
The inspection was a renewal visit conducted on January 6, 2020, to review the facility's compliance and implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several violations related to training, medication storage, medication administration, sanitary conditions, and posting of licenses were identified and addressed with corrective actions.
Citations (9)
2600 3.c. The home did not post the current violation report dated 3/15/2019 and a copy of 55 Pa.Code Chapter 2600 in a conspicuous and public place.
2600 65e. Direct care staff person A had no documented training hours for the training year September 2018 to August 2019.
2600 65f. Direct care staff person A did not receive training in medication self-administration, resident needs, infection control, personal care, safe management, or care for residents with mental illness or intellectual disability during the training year September 2018 to August 2019.
2600 65g. Staff person A did not receive fire safety training completed by a fire safety expert or trained staff, emergency preparedness, resident rights, Older Adult Protective Services Act, or falls and accident prevention training during the training year September 2018 to August 2019.
2600 85a. On 11/12/19, resident #1's glucometer was shared with resident #2, constituting an unsanitary condition.
2600 183e. Resident #3 had an opened bottle of Latanoprost eye drops past the 6-week discard date on 1/3/2020 in the medication cart.
2600 185a. Resident #2's glucose log reading was 191 on 12/26/19 but the glucometer reading was 261; resident #3's prescribed Lorazepam was not present on the medication cart on 1/6/2020.
2600 187b. Resident #4's Indapamide was not administered on multiple days in September 2019, but staff person B had initialed the MAR as administered.
2600 187d. Resident #4's Indapamide, resident #5's Ativan, and resident #6's Lorazepam were not administered as prescribed on specified dates.
Report Facts
Residents Served: 35
Total Daily Staff: 35
Waking Staff: 26
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Loftus | Administrator | Named as Administrator and Legal Entity Representative signing plans of correction |
| Staff person A | Direct care staff person involved in training violations and termination status | |
| Staff person B | Staff person involved in medication administration errors |
Notice — May 7, 2019
Date: May 7, 2019
Visit Reason
The document serves as a renewal notification and license issuance for The Willows of Living Branches Personal Care Home following receipt of a renewal application.
Findings
The Department of Human Services confirms issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by law.
Inspection Report — Apr 30, 2019
Monitoring
Date: Apr 30, 2019
Visit Reason
The inspection was conducted as a partial, unannounced monitoring visit triggered by an incident.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to resident abuse, neglect, medication administration, and following prescriber's orders were found. Plans of correction including staff training, policy implementation, and ongoing monitoring were partially implemented as of the report date.
Citations (7)
Regulation 2600.15(c): The home did not immediately submit a plan of supervision or notice of suspension for a staff person alleged to have abused a resident.
Regulation 2600.16(c): Resident #1 was left unattended for 5 hours with a heating pad causing 2nd-degree burns, and the home did not report the incident to the Department until four days later.
Regulation 2600.42(b): Resident #1 was neglected when staff failed to remove a heating pad causing burns and did not notify the administrator timely.
Regulation 2600.186(b): Resident #1 was administered Silvadene prescribed for resident #2, violating medication use regulations.
Regulation 2600.187(d): Staff administered Silvadene without a doctor's order.
Regulation 2600.182(c): Resident #1 was administered Lasix 40 mg without correct resident identification on multiple dates.
Regulation 2600.187(d): Resident #3 was not administered Ativan as prescribed on 03/28/2019 at 1:30 pm.
Report Facts
Residents Served: 50
Total Daily Staff: 50
Waking Staff: 38
Number of Hospice Residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Loftus | Director of The Willows of Living Branches | Signed multiple plans of correction and legal entity representative |
| David Carrion | Department representative conducting inspection on 03/11/2019 |
Inspection Report — Dec 20, 2018
Annual Inspection
Date: Dec 20, 2018
Visit Reason
Annual inspection conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual inspection.
Inspection Report — May 3, 2018
Renewal
Date: May 3, 2018
Visit Reason
The document is a renewal application and license issuance for The Willows of Living Branches Personal Care Home, confirming the facility's renewal to operate under Title 55, PA Code, Chapter 2600.
Findings
The Department has approved the renewal application and issued a regular license. The Department will conduct an onsite annual inspection within the next twelve months to ensure compliance.
Notice — Apr 12, 2018
Date: Apr 12, 2018
Visit Reason
The document is a notice of a revised license issued due to a correction of the legal entity name and facility name for a Personal Care Home.
Findings
The revised license corrects the legal entity and facility name for The Willows of Living Branches under Hatfield Mennonite Home. The certificate permits operation with a maximum capacity of 80 persons.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the license correction notice letter. |
Notice — May 11, 2017
Date: May 11, 2017
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for Dock Meadows and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 24, 2017
Renewal
Date: Apr 24, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Dock Meadows Personal Care Home facility.
Findings
The inspection identified violations related to hot water temperature exceeding limits, missed medication administration signatures, and lack of a system to identify and document medication errors and patterns. Plans of correction were submitted and partially implemented at the time of the report.
Citations (3)
Regulation 55 Pa.Code §2600: Hot water temperature at sinks inside rooms #413 and #201 exceeded the maximum allowed 120°F, measuring 123.9°F and 121.1°F respectively.
Regulation 55 Pa.Code §2600.187(b): Medication administration records lacked initial signatures for resident #112, with missed documentation until 2:10pm on the inspection date.
Regulation 55 Pa.Code §2600.188(d): The facility lacked a system to identify and document medication errors and patterns, with multiple medication errors occurring between November 2016 and April 2017.
Report Facts
Number of Residents Served: 63
Total Daily Staff: 53
Waking Staff: 40
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Loftus | Personal Care Director | Named in medication administration violation and plan of correction. |
Notice — May 17, 2016
Date: May 17, 2016
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Dock Meadows' following receipt of a renewal application.
Findings
No inspection findings are reported. The letter states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Inspection Report — May 3, 2016
Renewal
Date: May 3, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Dock Meadows Personal Care Home facility on May 3, 2016.
Findings
Violations of 55 Pa.Code Chapter 2600 were found during the inspection. The report includes a specific deficiency related to the initial assessment documentation for a resident, with a plan of correction outlined.
Citations (1)
Regulation 65 Pa.Code §2600 requires a written initial assessment within 15 days of admission. The initial assessment for resident #1 was completed late and the wording was unclear regarding the admission date used.
Report Facts
Number of Residents Served: 52
Total Daily Staff: 52
Waking Staff: 39
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Loftus | Administrator | Named in relation to the plan of correction and signature on violation report. |
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
The document serves as a renewal notification and license issuance for The Willows of Living Branches Personal Care Home. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
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