Inspection Report
Follow-Up
Census: 42
Capacity: 80
Deficiencies: 2
Aug 19, 2025
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident, with a follow-up to verify the submitted plan of correction.
Findings
The facility was found to have deficiencies related to the annual medical evaluation and additional resident assessments, which were corrected with a submitted plan of correction accepted on 09/18/2025. The facility implemented processes to ensure ongoing compliance.
Deficiencies (2)
| Description |
|---|
| The annual medical evaluation for a resident was not signed or dated by the medical professional and lacked the license number. |
| The resident support plan did not include a finalized date. |
Report Facts
Residents Served: 42
License Capacity: 80
Current Hospice Residents: 2
Total Daily Staff: 51
Waking Staff: 38
Resident Support Staff: 0
Residents Age 60 or Older: 42
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 38
Capacity: 80
Deficiencies: 5
Jun 25, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as an interim review to verify the full implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including breaches in record confidentiality, facility maintenance issues such as a missing ceiling tile and water leakage, smoking area guideline violations, medication administration errors, and improper medication storage procedures. All deficiencies had accepted plans of correction with completion dates set for July 19, 2025, and were noted as implemented by July 28, 2025.
Deficiencies (5)
| Description |
|---|
| Resident records were found accessible on an unattended, unlocked laptop in the medication room. |
| A ceiling tile was missing in the basement by the elevators with water leaking into a garbage can. |
| Cigarette butts were found both inside and outside designated smoking areas, indicating non-compliance with smoking area guidelines. |
| Staff person was observed administering medications without moving the medication cart within the vicinity of the resident. |
| Blood glucose readings were improperly recorded on the medication administration record, indicating storage and documentation errors. |
Report Facts
License Capacity: 80
Residents Served: 38
Current Residents in Hospice: 3
Residents Age 60 or Older: 38
Residents with Mobility Need: 8
Cigarette Butts Found: 17
Total Daily Staff: 46
Waking Staff: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Responsible for implementing corrective actions and systemic quality improvements across multiple deficiencies | |
| Nurse Educator | Conducted HIPAA/privacy in-service and audits for record confidentiality deficiency | |
| Nurse Manager | Responsible for daily privacy rounds and monitoring compliance with record confidentiality | |
| Maintenance Supervisor | Responsible for building maintenance monitoring and smoking area compliance | |
| Director of Nursing (DON) | Responsible for medication administration corrective actions and monitoring |
Inspection Report
Follow-Up
Census: 37
Capacity: 80
Deficiencies: 6
Apr 29, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify that the submitted plan of correction was fully implemented following previous reviews on 04/29/2025, 05/01/2025, 05/02/2025, and 05/05/2025.
Findings
The facility was found to have multiple deficiencies related to food labeling and storage, fire drill record keeping and evacuation procedures, incomplete resident medical evaluations, and non-compliant smoking area furnishings. All deficiencies had accepted plans of correction with completion dates in June 2025 and were reported as implemented by July 2025.
Deficiencies (6)
| Description |
|---|
| Unlabeled and undated food items found in the first-floor freezer and refrigerator. |
| Food stored in an opened and unsealed plastic bag in the first-floor freezer. |
| Fire drill records did not note the number of residents evacuated during drills. |
| Residents receiving hospice services were not evacuated during fire drills as required by policy. |
| Resident medical evaluation was missing temperature, special health and dietary needs, ability to self-administer medications, and body positioning/movement information. |
| Non-compliant cushions in the smoking area were not made with fire resistant materials. |
Report Facts
License Capacity: 80
Residents Served: 37
Current Hospice Residents: 4
Staffing Hours - Total Daily Staff: 44
Staffing Hours - Waking Staff: 33
Staffing Hours - Resident Support Staff: 0
Number of cushions: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Named as person responsible for food labeling and storage deficiencies and related corrective actions. | |
| Administrator | Named as person responsible for fire drill record keeping, designated meeting place deficiencies, and ongoing compliance monitoring. | |
| Maintenance Director | Named as person responsible for fire drill record keeping and smoking area compliance monitoring. | |
| Resident Wellness Director | Named as person responsible for ensuring completeness of resident medical evaluations and related audits. |
Inspection Report
Renewal
Census: 40
Capacity: 80
Deficiencies: 8
Mar 18, 2025
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including lack of operable bedside lamps, improper food storage, outdated food items, lint accumulation in dryer, smoking area hazards, unlabeled OTC medications, improper medication storage and documentation, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented or scheduled for implementation.
Deficiencies (8)
| Description |
|---|
| Resident room 118 did not have a lamp within reach of the resident’s bed. |
| A 10lb box of Smithfield Pork Sausage in the freezer was opened and not sealed. |
| Dented cans of sliced peaches and mandarin oranges were located in the basement dry food storage area. |
| Accumulation of lint observed in the base of the commercial clothes dryer. |
| Designated smoking area contained cigarette butts and a lighter. |
| OTC medications and CAM supplements for Residents #4 and #5 were not labeled with resident names. |
| Medication storage procedures were deficient: blood glucose readings not matching MAR, and several PRN medications unavailable at inspection. |
| Resident #8's support plan did not include hospice care services. |
Report Facts
License Capacity: 80
Residents Served: 40
Staffing Hours: 48
Waking Staff: 36
Current Hospice Residents: 6
Residents Age 60 or Older: 40
Residents with Mobility Need: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Responsible for correcting lighting, lint removal, and smoking area deficiencies. | |
| Dietary Manager | Responsible for correcting food storage and outdated food deficiencies. | |
| Nursing Supervisor | Responsible for labeling OTC medications and correcting medication storage/documentation. | |
| Facility Administrator | Responsible for overseeing lighting and smoking area corrective actions. | |
| Director of Nursing | Responsible for medication audits and updating resident support plans. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 80
Deficiencies: 9
Dec 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation, including review of submitted plans of correction and follow-up on compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to submit a final incident report timely, inadequate staffing levels especially during overnight shifts, incomplete and delayed resident assessments, deficiencies in fire drill documentation and scheduling, and failure to meet evacuation time standards. Corrective actions and training plans were implemented to address these issues.
Complaint Details
The inspection was complaint-driven, investigating incidents including a resident fall resulting in death, staffing adequacy, and compliance with resident assessment and fire safety regulations. Substantiation status is not explicitly stated.
Deficiencies (9)
| Description |
|---|
| Failure to submit a final incident report to the Department regarding the death of a resident following the initial incident report. |
| Resident abuse prevention violation due to inadequate supervision leading to a resident fall and subsequent death. |
| Inadequate staffing on overnight shift with only two staff present when three were scheduled, insufficient to meet resident evacuation needs. |
| Fire drill records missing AM/PM designation for drill time. |
| Evacuation times exceeded the safe evacuation time specified by fire safety expert. |
| Fire drills routinely conducted at predictable times during sleeping hours with extra staff present, violating scheduling requirements. |
| Annual medical evaluation for a resident was incomplete, missing health status information. |
| Initial resident assessments were not completed within 15 days of admission for multiple residents. |
| Annual resident assessments missing required information and failure to complete updated assessments after significant condition changes. |
Report Facts
Residents served: 37
License capacity: 80
Staffing levels overnight: 2
Staffing levels scheduled overnight: 3
Residents requiring assistance to evacuate: 17
Fire drill evacuation time (safe): 515
Fire drill evacuation time (actual): 552
Fire drill evacuation time (updated safe): 570
Fire drill evacuation time (updated actual): 574
Staff participating in fire drills: 3
Staff participating in fire drills: 8
Residents requiring two person assist: 1
Residents requiring one person assist: 12
Residents requiring initial cuing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Responsible for addressing immediate violations, conducting investigations, and overseeing corrective actions |
| Resident Wellness Director | Resident Wellness Director (RWD) | Responsible for compliance with resident care, assessments, and training |
| Facilities Director | Facilities Director | Responsible for fire drill compliance and facility safety |
| Staff Member A | Administrator | Commented on protocol for residents with cognitive decline |
| Staff Member B | Wellness Director | Noted resident cognitive decline and assessment schedule |
| Fire Chief Sean Connolly | Fire Chief | Provided fire inspection report and updated evacuation times |
Inspection Report
Renewal
Census: 33
Capacity: 80
Deficiencies: 17
Mar 14, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including missed blood sugar checks, confidentiality breaches, incomplete background checks, staff qualification issues, training deficiencies, uncovered trash receptacles, missing emergency phone numbers, inadequate lighting, outdated food, missed fire drills, fire safety inspection delays, improper smoking area use, unsecured medications, uncalibrated glucometer, failure to follow prescriber's orders, expired diabetic training, and incomplete resident support plans. Plans of correction were accepted and implemented with ongoing audits and re-education scheduled.
Deficiencies (17)
| Description |
|---|
| Resident #1 did not receive blood sugar checks as ordered and missed readings were not reported to the Department. |
| Licensing inspection summary from previous inspection was found in a location violating resident record confidentiality. |
| Direct Care staff A was hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person B did not receive required fire safety training and training on The Older Adult Protective Services Act in 2023. |
| Two trash cans in the main kitchen were uncovered, allowing penetration of insects and rodents. |
| Emergency telephone numbers were not posted near outgoing landlines in the dining room, private dining room, and resident room #123. |
| Resident room 221 did not have a bedside lamp within reach of the resident's bed. |
| Food items in freezer and refrigerator were not dated. |
| No fire drill was conducted in March 2023; no verification of contacting regional director during COVID outbreak. |
| Fire safety inspection was not conducted within the required 12-month period. |
| Fire drills from January to December 2023 used only the front exit route. |
| Smoking materials found in a non-smoking area near the home’s entrance. |
| Pill box with medications was left unsecured on dresser in resident room; resident door not locked when room vacated. |
| Resident #2's glucometer was not calibrated to the correct date and time. |
| Resident #1 did not receive blood sugar checks as prescribed on specified dates. |
| Staff A, B, and C had diabetic training more than 12 months ago and were not currently certified. |
| Resident #3’s support plan lacked documentation of hospice service start date; resident self-administered medications contrary to plan. Resident #4’s support plan lacked documentation regarding use of a bed cane. |
Report Facts
Residents Served: 33
License Capacity: 80
Total Daily Staff: 47
Waking Staff: 35
Current Hospice Residents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Takas | Trainer | Re-educated direct care staff on Diabetes Management, Insulin Administration and Blood Glucose Monitoring |
Inspection Report
Follow-Up
Census: 30
Capacity: 80
Deficiencies: 2
Sep 5, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Two deficiencies were noted related to direct care staff qualifications and preadmission screening documentation, both of which had corrective actions accepted and implemented by October 19, 2023.
Deficiencies (2)
| Description |
|---|
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident #1's preadmission screening form was completed after admission, not within 30 days prior as required. |
Report Facts
License Capacity: 80
Residents Served: 30
Total Daily Staff: 36
Waking Staff: 27
Residents with Mobility Need: 6
Inspection Report
Follow-Up
Census: 28
Capacity: 80
Deficiencies: 1
Jul 27, 2023
Visit Reason
The inspection visit was conducted as a partial, unannounced follow-up to an incident, to review the submitted plan of correction and verify compliance.
Findings
The submitted plan of correction was determined to be fully implemented with no additional concerns identified. The facility re-educated staff on abuse prevention and implemented ongoing resident and staff interviews to ensure rights are respected.
Deficiencies (1)
| Description |
|---|
| Staff person A was rough when providing care to residents, including rubbing a resident very hard during showering and showing aggressive behavior. |
Report Facts
License Capacity: 80
Residents Served: 28
Total Daily Staff: 34
Waking Staff: 26
Residents Age 60 or Older: 28
Residents with Mobility Need: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | RCP | Placed on administrative leave pending investigation due to abuse allegations |
Inspection Report
Renewal
Census: 33
Capacity: 80
Deficiencies: 2
Dec 21, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations on 12/21/2022 and 12/22/2022.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. Two deficiencies were identified related to staff training on emergency medical plan and reporting, and medication record discrepancies, both of which were corrected with training and audits.
Deficiencies (2)
| Description |
|---|
| Staff person A did not receive initial training in Emergency Medical Plan or Reporting of reportable incidents and conditions within 40 scheduled working hours. |
| Medication administration records (MAR) for two residents did not match medication labels, requiring updates and re-education of staff. |
Report Facts
License Capacity: 80
Residents Served: 33
Total Daily Staff: 45
Waking Staff: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Trained staff person A on Emergency Medical Plan and reporting; discussed audit results during QI meetings |
| Regional Director of Care Services | Regional Director of Care Services (RDCS) | Re-educated Executive Director and Support Nurses on regulatory requirements |
| Care Services Manager | Care Services Manager (CSM) | Verified medication orders and audited medication cart and records |
Inspection Report
Follow-Up
Census: 29
Capacity: 80
Deficiencies: 5
Apr 28, 2022
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident reported at the facility.
Findings
The inspection found violations related to incident reporting delays, abuse, treatment of residents without dignity and respect, and inadequate staff orientation in fire safety and resident rights. Corrective actions including staff termination, training, audits, and ongoing monitoring were implemented and found to be fully compliant by the follow-up date.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident involving a staff member yelling at a resident within 24 hours. |
| Abuse: Agency staff member pulled a resident's arm causing bruising and pushed the resident onto a toilet seat. |
| Failure to treat a resident with dignity and respect; staff member was mean and yelled at the resident. |
| Agency staff member did not receive first day fire safety orientation training. |
| Agency staff member did not receive orientation within 40 scheduled working hours on resident rights, protective services act, emergency medical plan, and reporting of incidents. |
Report Facts
License Capacity: 80
Residents Served: 29
Total Daily Staff: 40
Waking Staff: 30
Residents with Mobility Need: 11
Residents Age 60 or Older: 29
Inspection Report
Routine
Deficiencies: 0
Jan 7, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 30
Capacity: 80
Deficiencies: 12
Dec 8, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified several deficiencies including a non-operational CO2 detector, unsecured dumpster, lack of exhaust fans in certain bathrooms, medication storage issues, incomplete pre-admission screening forms, and documentation deficiencies in resident assessments and support plans. Plans of correction were submitted and accepted with ongoing monitoring and audits planned.
Deficiencies (12)
| Description |
|---|
| The CO2 detector in the boiler room was not operational at time of inspection. |
| The outside dumpster was not closed and left vulnerable to possible infestation. |
| The first-floor bathroom across from room 101 and the basement bathroom across from the activities room did not have a window or any functioning exhaust fan. |
| Resident 1 is prescribed a PRN medication that was not available on the Medication cart at the time of inspection. |
| The pre-admission screening form for Resident 2 did not indicate if the home could meet the resident’s needs. |
| The assessment plan for Resident 3 was not completed within 15 days of admission. |
| The annual Assessment Plan for Resident 4 was not completed timely; previous assessment was completed 6/16/2020. |
| The support plan for Resident 3 was not completed within 30 days of admission. |
| The annual support Plan for Resident 4 was not completed timely; previous assessment date redacted. |
| The Resident Assessment and Support Plan for Resident 2 had conflicting information regarding mobility assessment. |
| The Resident Assessment and Support Plan of Resident 4 did not indicate that the resident is utilizing a bed cane on their bed. |
| The Resident Assessment and Support Plan of Resident 2 was not dated by the resident who participated and signed the RASP. |
Report Facts
License Capacity: 80
Residents Served: 30
Total Daily Staff: 41
Waking Staff: 31
Residents 60 Years or Older: 30
Residents with Intellectual Disability: 1
Residents with Mobility Need: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings and plans of correction related to audits, in-services, and corrective actions. | |
| Maintenance Tech | Installed and tested CO2 detectors as part of plan of correction. | |
| Regional Director of Care Services | Conducted in-service on support plan documentation compliance. | |
| CSM | Involved in audits and in-services related to resident assessments and support plans. |
Inspection Report
Renewal
Deficiencies: 0
Apr 27, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections on 04/27/2021 and 05/03/2021 for the facility Willowbrook Place.
Findings
No regulatory citations were identified as a result of this inspection.
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