34 Reports
Notice — Jun 23, 2026
Date: Jun 23, 2026
Visit Reason
The document is a response to a request for a waiver of 55 Pa. Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in a personal care home.
Findings
The waiver is granted with conditions including medication technicians completing Department-approved training, receiving in-person training from licensed healthcare professionals, annual training requirements, and facility policies for monitoring and documentation of medication administration.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jun 16, 2026
Follow-Up
Date: Jun 16, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to medication storage, administration, and support plan documentation. Several deficiencies were identified previously, including failure to follow narcotic destruction procedures, missed medication doses, unlicensed medication administration, and incomplete resident support plans, all of which were addressed with staff education and policy reinforcement.
Citations (4)
185a - The facility failed to have two licensed personnel witness and document medication destruction as required by the narcotic policy. Narcotic counts were not completed on medications stored in the overflow cart.
187d - A resident did not receive a prescribed medication dose at 2:00 p.m. because the medication was not available in the home at the time of administration.
190b - Insulin injections were administered by unlicensed staff without an approved waiver, violating state regulations requiring licensed personnel for administration.
227a - A resident's support plan was incomplete, lacking service descriptions and plans of care for assessed needs in personal hygiene, managing finances, and shopping.
Report Facts
Residents Served: 44
Current Hospice Residents: 6
Staff Counts: 56
Waking Staff: 42
Inspection Report — May 7, 2026
Follow-Up
Date: May 7, 2026
Visit Reason
The inspection was conducted as a complaint and interim review to verify the submitted plan of correction for the facility.
Complaint Details
The inspection was complaint-related and interim in nature. The plan of correction was reviewed and determined to be fully implemented.
Findings
The facility failed to follow a prescriber's medication order for a resident, resulting in a missed medication dose. The plan of correction was accepted and fully implemented as of 06/02/2026.
Citations (1)
187d - Follow Prescriber's Orders: A resident prescribed medication to be given when pulse is greater than 55 was not administered the medication despite meeting the criteria. Medication staff failed to follow physician orders and overlooked medication parameters.
Report Facts
Residents Served: 41
Current Residents Hospice: 4
Inspection Report — Apr 15, 2026
Follow-Up
Date: Apr 15, 2026
Visit Reason
The inspection was an unannounced partial review triggered by an incident to verify the submitted plan of correction was fully implemented.
Findings
The facility was found to have fully implemented the plan of correction related to deficiencies in preadmission screening documentation and additional resident assessments following significant condition changes.
Citations (2)
224a - Preadmission screening form did not include documentation that the resident's needs could be met by the services provided by the home prior to admission.
225c - Resident assessments did not include addendums when there were significant changes in mental status, suicidal ideations, or use of a Wander Guard.
Report Facts
Residents Served: 42
Current Hospice Residents: 6
Inspection Report — Mar 4, 2026
Renewal
Date: Mar 4, 2026
Visit Reason
The inspection was conducted as a renewal and incident review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including contract inaccuracies, training deficiencies, safety hazards, medication management issues, and recordkeeping errors. Plans of correction were accepted and implemented with ongoing monitoring and training.
Citations (22)
25c8 Smoking: The resident-home contract for Resident #1 did not include the current home smoking rule, inaccurately stating the property is smoke free despite a designated smoking area.
65d Initial Direct Care Training: Direct Care Staff Person A provided unsupervised ADL services without completing required training and competency testing.
65e 12 Hours Annual Training: Direct Care Staff Members B and C did not receive the required 12 hours of annual training related to job duties for 2025.
65g Annual Training Content: Staff Persons B and C did not receive annual training in fire safety, emergency preparedness, resident rights, OAPSA, and falls prevention during 2025.
85e Trash Outside Home: Dumpster lid was found open allowing access to insects and rodents.
86b Bathroom: The hallway C1 bathroom near room 100 had an inoperable exhaust fan and no window or other ventilation source.
92 Windows: Ten window screens on operable windows at the back of the facility were tattered and torn, with tears up to 10 inches long.
102f Towel/Washcloth/Soap: A used bar of soap was found in the 2nd floor spa shower that was not labeled with a resident’s name.
103b Clean/Sanitized Kitchen Surfaces: Oven grill was not cleaned after last use and had leftover food debris.
103i Outdated Food: Eight thickened cranberry cocktail cups expired on 11/6/25 were found and removed.
121a Unobstructed Egress: A combination lock on the courtyard gate blocked egress from the courtyard.
132c Fire Drill Records: Fire drill records showed inconsistent resident counts evacuated compared to residents in the home, with repeat violations.
132d Evacuation: The home exceeded the maximum safe evacuation time of 8 minutes 35 seconds during multiple fire drills.
141b1 Annual Medical Evaluation: Resident 6's medical evaluation was undated and lacked physician confirmation of appropriateness for personal care home placement.
144c1 Smoking Area Guidelines: Over 50 cigarette butts were discarded in mulch near the cement patio, indicating improper disposal.
181c Self-administration Assessment: Resident #1 self-administered medication without a documented assessment authorizing self-administration.
183e Storing Medications: Resident #2’s Pregabalin medication card was tampered with tape holding capsule #16 in place.
185a Implement Storage Procedures: Resident #3’s PRN medications were not available for administration if needed; daily blood glucose readings for Residents #1 and #2 were not provided.
187d Follow Prescriber's Orders: Resident #4 was administered Metoprolol despite vital signs indicating medication should be held; warm eye compress treatments were administered late.
190c Record of Training: Staff Person C’s annual medication administration training record lacked their signature.
225c Additional Assessment: Resident #6’s significant change assessment was delayed following hospice admission.
252 Record Content: Resident #5’s and Resident #7’s records lacked required demographic information including identifying marks and physical characteristics.
Report Facts
Residents Served: 43
Resident Support Staff: 43
Total Daily Staff: 96
Waking Staff: 72
Current Hospice Residents: 6
Residents Age 60 or Older: 45
Residents with Mobility Need: 10
Number of Cigarette Butts: 50
Number of Torn Window Screens: 10
Expired Food Items: 8
Inspection Report — Jan 9, 2026
Complaint Investigation
Date: Jan 9, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of resident abuse and other regulatory concerns at Willowbrook Place.
Complaint Details
The visit was complaint-related, investigating allegations of resident abuse, neglect, improper resident rights restrictions, and regulatory noncompliance. The complaint was substantiated with multiple violations found.
Findings
Multiple violations were found including failure to report an incident, resident abuse and neglect, improper resident association restrictions, unsafe resident equipment, incomplete medical evaluations and assessments, inadequate support plan documentation, unsigned support plans, and improper grounds for resident discharge.
Citations (10)
16c - The home failed to report a resident fall resulting in a hematoma to the Department within 24 hours as required.
42b - Resident abuse occurred when staff failed to intervene in inappropriate resident sexual interactions and did not provide adequate supervision.
42o - Staff improperly restricted a resident's right to freely associate and communicate with another resident.
81b - A resident's bedside mobility device was not properly secured, posing a risk of injury.
141a - A resident's initial medical evaluation did not indicate if the resident can safely avoid poisons.
225a - A resident's initial assessment was delayed and did not document use of mobility devices for ambulation.
225c - The resident's annual assessment did not include use of a bedside mobility device despite reported use.
227d - Resident support plans lacked documentation on how medical and behavioral care needs would be met.
227g - Residents did not sign their support plans and there was no indication of refusal or inability to participate.
228h - A 30-day discharge notice was issued without listing permitted conditions and cited non-compliance without evidence.
Report Facts
Residents Served: 42
Total Daily Staff: 51
Waking Staff: 38
Resident Support Staff: 0
Inspection Report — Aug 19, 2025
Follow-Up
Date: 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.
Citations (2)
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
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 — Jun 25, 2025
Follow-Up
Date: 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.
Citations (5)
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
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 — Apr 29, 2025
Follow-Up
Date: 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.
Citations (6)
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
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 — Mar 18, 2025
Renewal
Date: 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.
Citations (8)
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
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 — Dec 18, 2024
Complaint Investigation
Date: 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.
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.
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.
Citations (9)
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
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 |
Notice — Mar 27, 2024
Date: Mar 27, 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 qualifications has been granted.
Findings
The waiver allows a specified direct care staff member to work while enrolled in classes to obtain her General Education Diploma by September 27, 2024, with conditions including prohibition from administering medication until completion and documentation requirements.
Report Facts
Waiver expiration date: Sep 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Mar 14, 2024
Renewal
Date: 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.
Citations (17)
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
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 — Sep 5, 2023
Follow-Up
Date: 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.
Citations (2)
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
Residents Served: 30
Total Daily Staff: 36
Waking Staff: 27
Residents with Mobility Need: 6
Inspection Report — Jul 27, 2023
Follow-Up
Date: 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.
Citations (1)
Staff person A was rough when providing care to residents, including rubbing a resident very hard during showering and showing aggressive behavior.
Report Facts
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 — Dec 21, 2022
Renewal
Date: 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.
Citations (2)
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
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 — Apr 28, 2022
Follow-Up
Date: 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.
Citations (5)
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
Residents Served: 29
Total Daily Staff: 40
Waking Staff: 30
Residents with Mobility Need: 11
Residents Age 60 or Older: 29
Inspection Report — Jan 7, 2022
Routine
Date: 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 — Dec 8, 2021
Renewal
Date: 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.
Citations (12)
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
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 — Apr 27, 2021
Renewal
Date: 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.
Inspection Report — Oct 29, 2020
Renewal
Date: Oct 29, 2020
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements for Willowbrook Place.
Findings
The inspection identified multiple deficiencies related to food labeling, fire department notification, exit signage, medication storage and labeling, blood glucose documentation, and following prescriber's orders. All deficiencies had plans of correction implemented and verified.
Citations (7)
2600.103.e Food served and returned from an individual’s plate may not be served again or used in preparation of other dishes. The home's kitchen contained unlabeled and undated food items in the refrigerator.
2600.124 The home did not have documentation of notification to the local fire department regarding the location, layout, capacity, and mobility needs of the residents.
2600.133.1 Exit signs must be placed at all exits. An exit door was labeled as 'Not an Exit' despite being shown as an exit on the fire evacuation diagram.
2600.183.e Prescription medications must be stored properly. Resident #1's Humalog insulin pen was not dated when opened for use.
2600.184.a Prescription medication containers must have pharmacy labels including prescribed dosage and instructions. Resident #2's Budesonide inhalation medication label lacked daily dosage information.
2600.185.a The home must implement procedures for safe storage and documentation of medications. Blood glucose readings for three residents were inaccurately recorded on the Medication Administration Record.
2600.187.d The home must follow prescriber's orders. Resident #5's medication was not held as ordered when heart rate was below threshold.
Report Facts
Residents Served: 31
Current Hospice Residents: 3
Residents with Mobility Need: 13
Residents with Physical Disability: 2
Residents 60 Years or Older: 31
Residents Diagnosed with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Pisano | Administrator | Named as facility administrator |
| Amy Deluca | Lead Inspector | Lead inspector for the renewal inspection |
| Michele Moskalczyk | Human Services Licensing Supervisor | Reviewer and licensing supervisor |
Inspection Report — Aug 21, 2020
Routine
Date: Aug 21, 2020
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 — Jul 22, 2020
Follow-Up
Date: Jul 22, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to medication storage and security violations involving missing narcotic tablets. Audits and re-education measures were established to ensure ongoing compliance.
Citations (2)
2600.183.b requires prescription medications and syringes to be kept locked. On 7/16/20, the narcotic drawer was left unlocked and unattended, resulting in 28 missing Percocet tablets.
2600.185.a requires procedures for safe storage and handling of medications. Staff failed to count narcotics at shift change on 7/16/20, contributing to the missing Percocet tablets incident.
Report Facts
Residents Served: 39
Missing narcotic tablets: 28
Total Daily Staff: 52
Waking Staff: 39
Current Hospice Residents: 4
Inspection Report — Jul 8, 2020
Follow-Up
Date: Jul 8, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to updating a resident's support plan to address exit seeking behavior. Continued compliance was required.
Citations (1)
2600.227d requires documentation in the resident’s support plan of medical and behavioral care services or referrals. Resident #1’s support plan was not updated after elopement incidents to reflect exit seeking behavior and supervision needs.
Report Facts
Residents Served: 39
Current Hospice Residents: 4
Residents with Mobility Need: 13
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Deluca | Lead Inspector | Lead inspector during the 07/08/2020 partial inspection |
| Michele Moskalczyk | Lead Reviewer | Lead reviewer for follow-up document submissions and final review |
| Mark Pisano | Administrator | Facility administrator named in the report header |
Inspection Report — May 8, 2020
Date: May 8, 2020
Visit Reason
The document reports on multiple licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing at Willowbrook Place on various dates in 2020.
Findings
No regulatory citations were identified as a result of the inspections conducted on the listed dates.
Inspection Report — Nov 12, 2019
Annual Inspection
Date: Nov 12, 2019
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on November 8 and November 12, 2019, to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall but had several deficiencies including expired cosmetology salon license, uncovered enabler bar on a resident's bed, excessive hot water temperature in a resident's bathroom sink, metal end caps creating hazards, dented food cans, lint accumulation in dryer traps, inaccurate fire drill records, improper exit signage, outdated resident medical evaluations, combustible materials in smoking areas, missed medication orders, and incomplete resident support plans. Corrective actions and monitoring plans were implemented for each deficiency.
Citations (12)
55 PA Code § 2600.18: The home provided cosmetology salon services without a current license, as the license expired on 1/31/2019.
55 PA Code § 2600.81b: Resident #1 had an enabler bar on their bed without a cover, posing a possible safety hazard.
55 PA Code § 2600.89b: Hot water temperature in resident room #122's bathroom sink measured 122.5°F, exceeding the 120°F limit.
55 PA Code § 2600.95: Metal end caps on heating baseboards near dining areas were found loose and created hazards to residents.
55 PA Code § 2600.103i: Dented food cans were found in stock, which is prohibited.
55 PA Code § 2600.105g: A large amount of lint was observed in the lint trap of the commercial gas dryer and beneath the lint trap of the Speed Queen dryer.
55 PA Code § 2600.132c: Fire drill records did not include minutes and seconds for drill times, instead using incorrect numeric values.
55 PA Code § 2600.133a: The dining room exit sign was covered with a 'NOT AN EXIT' sign, which conflicted with the fire evacuation diagram.
55 PA Code § 2600.141b: Resident #2's most recent annual medical evaluation was completed late on 4/9/19 instead of by 3/28/19.
55 PA Code § 2600.144c: Combustible papers and cigarette butts accumulated in the resident smoking area near metal cigarette butt cans.
55 PA Code § 2600.187d: Resident #2 and Resident #3 were prescribed medications that were not available in the home at the time.
55 PA Code § 2600.227d: Resident #1 and Resident #4's support plans did not initially document use of special adaptive equipment such as plastic plates and bed cane/enabler bars.
Report Facts
Residents Served: 48
Staff: 57
Waking Staff: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Executive Director | Named in multiple findings and plans of correction including cosmetology license, enabler bar, hot water temperature, furniture repair, fire drill records, and smoking area combustibles |
Notice — Jan 30, 2019
Date: Jan 30, 2019
Visit Reason
The document serves as a renewal notice and license issuance for Willowbrook Place Personal Care Home following receipt of a renewal application dated January 28, 2019.
Findings
No inspection findings are reported. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Inspection Report — Jan 25, 2019
Complaint Investigation
Date: Jan 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations related to resident care and compliance with Personal Care Homes regulations.
Complaint Details
The investigation was triggered by a complaint regarding suspected abuse and neglect of Resident #1, including failure to report incidents and provide adequate care. The complaint was substantiated based on findings of neglect and regulatory violations.
Findings
The facility was found to have multiple violations including failure to submit timely incident reports, inadequate assistance with activities of daily living, neglect of a resident resulting in stage 2 decubitus ulcers, unsafe environmental conditions, incomplete medical evaluations, and medication administration errors. Plans of correction were partially implemented with ongoing monitoring required.
Citations (16)
Regulation 55 Pa.Code §2600.16(c): The home failed to submit an incident report within 24 hours following an investigation of suspected abuse for Resident #1.
Regulation 55 Pa.Code §2600.23(a): The home failed to provide identified shower services to Resident #1 despite refusals, and did not offer additional assistance.
Regulation 55 Pa.Code §2600.42(b): Resident #1 was neglected resulting in stage 2 decubitus ulcers due to lack of assistance with showers and observation.
Regulation 55 Pa.Code §2600.227(d): The home's Resident Assessment Support Plan (RASP) failed to document necessary assessments including transferring, ambulating, and cognitive needs for Resident #4.
Regulation 55 Pa.Code §2600.88(a): Yellow tape creating a tripping hazard on stairwell steps was removed immediately during inspection to prevent resident injury.
Regulation 55 Pa.Code §2600.91: Emergency telephone numbers were missing or not posted in Resident #1 and #2's rooms as required by regulation.
Regulation 55 Pa.Code §2600.95: The faucet lever in Resident #212's bathroom was faulty and required replacement; maintenance staff confirmed repair was needed.
Regulation 55 Pa.Code §2600.100(a): Maintenance staff evaluated and replaced unsafe steps on back gate stairs to ensure resident safety.
Regulation 55 Pa.Code §2600.121(a): Two wicker chairs obstructed an emergency exit and were moved to prevent egress obstruction.
Regulation 55 Pa.Code §2600.141(a)(2): Resident #3's documented medical evaluation was incomplete, missing temperature readings and physical exam details.
Regulation 55 Pa.Code §2600.144(c)(1): The home had cigarette butts improperly disposed of in smoking areas, posing a fire hazard.
Regulation 55 Pa.Code §2600.187(a): Resident #4's medication record was incomplete and the medication administration record (MAR) was not properly documented.
Regulation 55 Pa.Code §2600.132(a): The facility failed to conduct an unannounced monthly fire drill as required.
Regulation 55 Pa.Code §2600.132(d): The fire safety expert was unreachable and the facility lacked documentation of fire safety compliance.
Regulation 55 Pa.Code §2600.132(h): Residents were not evacuated to designated meeting places during fire drills, causing confusion.
Regulation 55 Pa.Code §2600.227(d): Resident assessments lacked timely and complete documentation of needs and services in support plans.
Report Facts
Residents Served: 54
Current Hospice Residents: 5
Total Daily Staff: 67
Waking Staff: 50
Residents Age 60 or Older: 54
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Residents Served: 49
Current Hospice Residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Administrator / Executive Director | Named in multiple findings and plans of correction signatures |
| Rob Naro | Maintenance Director | Named in findings related to maintenance and fire safety |
| Wendy Sebolka | Lead LPN | Named in findings related to resident care and medical evaluations |
| Anne Graziano | Regional Nurse | Named in training and compliance monitoring related to abuse reporting |
| Angel Lyles | Regional Nurse | Named in compliance monitoring and training |
| Jason Harvey | Department Representative on-site during follow-up inspection | |
| Duane Valence | Department Representative on-site during inspections | |
| Kristin DeVries | Department Representative on-site during inspection |
Inspection Report — May 22, 2018
Complaint Investigation
Date: May 22, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The investigation was triggered by an incident involving Resident #1 who suffered a fall and later passed away. The facility was found to have delayed reporting the death and delayed completion of the required medical evaluation.
Findings
Two violations were found related to failure to report a resident's death timely and failure to complete a medical evaluation within required timeframes. Plans of correction were partially implemented with adequate progress noted.
Citations (2)
Regulation 55 Pa.Code §2600 requires reporting incidents to the Department within 24 hours. The facility failed to report Resident #1's death until 5/7/2018, after the resident passed away following a stay at a rehabilitation facility.
Regulation 55 Pa.Code §2600.141(a)(1) requires a medical evaluation within 60 days prior to admission or within 30 days after admission. Resident #1's medical evaluation was not completed until 4/4/2018, after admission.
Report Facts
Number of Residents Present: 51
Total Daily Staff: 68
Waking Staff: 51
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 51
Number of Residents with Mobility Needs: 17
Number of Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Executive Director | Named as the facility administrator and signer of violation reports and plans of correction |
| Amy Deluca | Department representative conducting the inspection on 5/22/2018 |
Inspection Report — Mar 27, 2018
Renewal
Date: Mar 27, 2018
Visit Reason
The inspection was an annual licensing renewal inspection conducted on March 27, 2018, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including hot water temperatures exceeding 120°F in resident rooms, heating unit needing repair, snow-covered hazardous steps, fire drill timing issues, and incomplete resident records. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (6)
55 Pa.Code §2600.89(b) - Hot water temperature in resident bedrooms exceeded 120 degrees Fahrenheit, with readings up to 126 degrees.
55 Pa.Code §2600.95 - Wall mounted heating unit in the East stairwell was leaking and baseboard grille was detached, creating a hazard.
55 Pa.Code §2600.100(b) - Steps from back gated patio to ground level were covered with snow, creating a hazardous condition.
55 Pa.Code §2600.132(d) - Fire safety expert evacuation time exceeded specified limits; fire drills were not routinely held at varied times.
55 Pa.Code §2600.132(g) - Fire drills were not held on different days and times as required, limiting staff and resident preparedness.
55 Pa.Code §2600.252 - Resident records lacked required descriptive information such as eye color, hair color, and identifiable marks.
Report Facts
Number of Residents Served: 51
Total Daily Staff: 53
Walking Staff: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Executive Director | Signed plan of correction and referenced in findings |
Notice — Feb 27, 2018
Date: Feb 27, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Willowbrook Place Personal Care Home 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.
Report Facts
Inspection Report — Mar 29, 2017
Renewal
Date: Mar 29, 2017
Visit Reason
The inspection was an annual licensing inspection conducted as a renewal of the facility license for Willowbrook Place.
Findings
The inspection found multiple violations of 55 Pa.Code Chapter 2600 related to facility safety, staff training, medication management, and fire safety. Plans of correction were submitted and partially implemented as of the report date.
Citations (7)
Regulation 55 Pa.Code §2600: The facility lacked a carbon monoxide detector in the laundry room, violating the Care Facility Carbon Monoxide Alarms Standards Act.
Regulation 55 Pa.Code §2600.65(i): Training records for staff persons A and B did not include the topic 'The Older Adult Protective Services Act'.
Regulation 55 Pa.Code §2600.144(c)(1): Smoking was observed outside the designated smoking area without proper fireproof receptacles, posing a fire hazard.
Regulation 55 Pa.Code §2600.183(d): Employee vaccinations were not properly stored separately from resident insulin vials in the medication closet refrigerator.
Regulation 55 Pa.Code §2600.183(e): Medication cart audit revealed an unwrapped half tablet and a loose tablet, indicating improper medication storage.
Regulation 55 Pa.Code §2600.183(e): Lead Med Aide reorganized the medication cart to reduce overcrowding and improve storage.
Regulation 55 Pa.Code §2600.184(c): A sample prescription medication for resident #1 lacked a label with administration instructions from the prescriber.
Report Facts
Number of Residents Served: 54
Total Daily Staff: 56
Waking Staff: 42
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 9
Number of Residents 60 Years or Older: 54
Number of Residents with Mobility Need: 2
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Executive Director | Named in plan of correction signatures and oversight of compliance |
| Jesse Hummel | Department representative conducting the inspection | |
| Anne O'Haire | Department representative conducting the inspection |
Inspection Report — Sep 22, 2016
Renewal
Date: Sep 22, 2016
Visit Reason
The inspection was a licensing inspection conducted as a renewal and new license for Willowbrook Place, a Personal Care Home, to assess compliance with 55 Pa.Code Chapter 2600.
Findings
The facility was found to be in substantial compliance with regulations but had violations related to resident contracts, hospice resident evacuation procedures, food storage, lint accumulation in dryer vents, fire drill documentation, smoking area safety, and medication administration records. Plans of correction were submitted and partially implemented.
Citations (10)
55 Pa.Code §2600.25(b): Resident contracts were not signed by residents for three admissions.
55 Pa.Code §2600.29a(b)(1): A hospice resident was not evacuated during a fire drill despite being actively dying.
55 Pa.Code §2600.29a(b)(4): Staff failed to evacuate a hospice resident during a fire drill and did not notify staff properly.
55 Pa.Code §2600.29a(b)(10): The resident's assessment and support plan did not specify evacuation procedures for a hospice resident.
55 Pa.Code §2600.103(g): Cookies in the main foyer hostess cart were not covered or stored in a sealed container.
55 Pa.Code §2600.105(g)(2): Lint accumulation was found on the sidewalk below the exterior dryer vents.
55 Pa.Code §2600.124: The facility's fire department notification letter did not include the total licensed capacity of the home.
55 Pa.Code §2600.132(c): The fire drill log did not indicate whether the drill was held in the AM or PM.
55 Pa.Code §2600.144(c)(1): An ashtray was found outside the designated smoking area near the laundry exit door.
55 Pa.Code §2600.187(a): Medication records lacked exact times for insulin administration as ordered by the physician.
Report Facts
Number of Residents Served: 53
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Murray | Executive Director | Signed the plan of correction and legal entity representative on violation report |
| Jacqueline L. Rowe | Director | Signed licensing letter dated October 17, 2016 |
Notice — December 18, 2020
Date: December 18, 2020
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Willowbrook Place' following receipt of the renewal application. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and advises that enforcement action may follow if noncompliance is found during the upcoming inspection.
Viewing
Loading inspection reports...
