Commonwealth Senior Living at Willow Grove

Computers on medication carts were left unlocked and unattended, and a resident assignment book was left unsecured, exposing medical information.

Staff members engaged in a physical altercation involving a firearm and alcohol consumption during a shift, creating a significant safety risk to residents.

Multiple cameras were recording in common areas and hallways without posted signage notifying residents that video recording was in progress.

The home failed to submit an incident report to the Department regarding an allegation of resident neglect involving inadequate morning care.

The resident-home contract lacked a signed statement informing the resident that rent rebate collection information would be kept in their record.

The home has not implemented its quality management plan, failing to conduct the required annual quality management review.

A resident was not treated with dignity and respect due to a full bedside commode and urinals being left uncleaned for several hours.

The home failed to report incidents of staff-led intimidation and physical abuse to the Department within the required 24-hour timeframe.

A staff member used intimidation tactics involving cold temperatures to force a resident out of bed and was witnessed slamming the resident against a wall.

Multiple residents did not receive required assistance with Activities of Daily Living (ADLs) as indicated in their assessment and support plans.

A resident did not receive required assistance with bathing, dressing, undressing, and care of clothes on multiple occasions.

Residents experienced neglect/mistreatment through long wait times for staff response to call pendants for hygiene and dressing needs.

The home failed to report two incidents involving residents falling and requiring emergency room treatment within the required 24-hour period.

The home does not have a quality management plan established or implemented.

Two staff members working in the home did not have required FBI background checks on file.

A direct care staff person lacked a high school diploma, GED, or active status on the Pennsylvania nurse aide registry.

Direct care staff training requirements for unsupervised ADL services were not fully documented.

Resident records in the 3rd floor nursing office were found unlocked, unattended, and accessible to unauthorized individuals.

Body wash and shampoo with manufacturer's warning labels were stored unlocked and accessible in a resident's bedroom.

A resident did not have access to an operable lamp or light source that could be turned on/off at their bedside.

A fire drill conducted on 10/9/19 showed an evacuation time of 14 minutes and 37 seconds, exceeding the maximum safe time of 12 minutes.