Willowbrook Place

A resident fall resulting in a head hematoma was not reported to the Department within the required 24-hour timeframe.

Staff failed to prevent residents from staying in a closed room together overnight without checks, despite medical documentation indicating a need for supervision for safety.

Staff failed to intervene or provide supervision during sexualized interactions between residents, including an incident where a resident was found partially unclothed in another resident's bed.

A resident's annual medical evaluation was not signed or dated by the medical professional and lacked their license number.

A resident's support plan did not include a date indicating when the plan was finalized.

Cigarette butts were found on the ground both inside and outside of the designated smoking areas.

Staff was observed transporting resident medications in a cup down a hallway without moving the medication cart to the resident's vicinity.

A missing ceiling tile in the basement caused water to leak into a garbage can.

An unattended, unlocked laptop containing resident information was observed in the open medication room.

A clear plastic bag of french fries was found unsealed in the freezer.

Fire drill records failed to note the number of residents evacuated during drills.

Residents receiving hospice services were not evacuated during a fire drill, and the facility did not attempt to enact the required Statement of Policy.

Frozen chicken fillets and green Jell-O were found in the freezer and refrigerator without labels or dates.

Resident room 118 did not have an operable lamp within reach of the resident's bed.

A box of pork sausage in the freezer contained an opened and unsealed plastic bag.

Cigarette butts and a lighter were found on the ground and in a flowerpot near the designated smoking area.

Dented cans of peaches and mandarin oranges were found in the basement dry food storage area.

An accumulation of lint was observed in the base of the commercial clothes dryer in the basement.

A resident experienced a fall from a second-floor landing due to inadequate supervision and staffing levels during a shift with a call-off.

The home failed to submit a final incident report to the Department regarding the death of a resident following the initial incident report.

Missed blood sugar checks for a resident were not reported to the Department within the required 24 hours.

A direct care staff member was performing unsupervised duties before a criminal background check was completed.

Resident privacy coding was improperly attached to a Licensing Inspection Summary in a visible location.

A direct care staff person did not have a high school diploma, GED, or active status on the Pennsylvania nurse aide registry.

A resident's preadmission screening form was completed after the required 30-day window prior to admission.