Willow Grove Post Acute

Inspectors wroteBased on record review and staff interview, the facility failed to accurately complete the PASARR (Preadmission Screening and Resident Review) documentation for 4 of 6 residents reviewed for PASARR compliance. (Resident R20, Resident 51, Resident 4 and Resident R2)

Inspectors wroteBased on observation, interviews with resident and staff and review of clinical records, it was determined that the facility failed to provide care and services to maintain adequate grooming for one of 24 resident records reviewed (Resident R68).

Inspectors wroteBased on clinical record review and interviews with resident and staff, it was determined that the facility did not ensure that physician orders for daily weights were followed for one of 24 residents reviewed (Resident R47).

Inspectors wroteBased upon observation, review of clinical records, interviews with facility residents and staff and review of facility policy, it was determined that the facility failed to ensure a resident received the necessary services and treatment to prevent pressure ulcers and to promote healing for one of 24 resident records reviewed (Resident R47)

Inspectors wroteBased on review of facility policies, clinical records, hospital records, care plans, fall investigations, observations, and interviews with staff and residents, it was determined that the facility failed to ensure residents received adequate assistants and interventions to prevent injury for three of 24 resident records reviewed. (Resident R2, Resident R47, Resident 101)

Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure that as needed antianxiety medication was discontinued in accordance with the physician for one of 24 records reviewed.

Inspectors wroteBased on observations and interviews with residents and staff and facility documentation determined that the facility failed to ensure safe and operable equipment were available for use relating to blood pressure cuffs, and two mobility assistance devises, (Hoyer and Sit-to-Stand lifts) for two of 24 residents reviewed. Resident R68 and R20)

Inspectors wroteBased on clinical record review, interviews with staff, review of hospital records and review of policy and procedure, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight or desirable body weight for one of twelve residents reviewed. (Resident R1)

Inspectors wroteBased on interviews with staff, and clinical record reviews, it was determined that the facility failed to ensure that clinical records were accurately documented for one of twelve residents reviewed. (Resident R1)

Inspectors wroteBased on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to unattended medication carts and medications for two of two nursing units reviewed. (First floor and Second floor)Findings Include: Review of facility policy titled, Administering Medications dated April 2019. Review of policy states, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Further review of facility policy revealed Policy Interpretation and Implementation- .20. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. [...]

Inspectors wroteBased on review of facility policy and review of clinical record, it was determined that the facility failed to ensure timely and accurate medication administration for two of five residents reviewed (Resident R1, and Resident R6)Review of facility policy 'Administering medications,' revised April 2019, indicates that medications are to be administered in a safe and timely manner as prescribed. Further review of policy indicates that medications are administered in accordance with prescriber orders, including any required time frames. Review of Resident R1's electronic medication administration report (e-MAR), dated September 21, 2025, revealed an order for Carbidopa Levodopa, extended release 70-280 milligrams (mg), scheduled to be administered at 9:00 am for Parkinson's disease (progressive disease of the central nervous system). [...]

Inspectors wroteBased on review of facility provided documentation, it was determined that the facility failed to address residents' concerns related to late call bell response time three of six residents reviewed. (Resident R3, R4, R5)

Inspectors wroteBased on review of facility provided documentation, interview with residents and observations, it was determined that facility did not ensure that call bells were properly functioning for one of six residents reviewed. (Resident R2)

Inspectors wroteBased on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency and the State Long-Term Care Ombudsman program phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to hopsice services, enternal feeding, and intravenous device for three of nineteen records reviewed (Resident R18, R36, and R80).

Inspectors wroteBased on clinical record reviews, interviews with residents and staff and reviews of policies and procedures and hospital records, it was determined that the facility failed to ensure that residents with bowel and bladder incontinence received care to maintain, restore or improve bowel and bladder function for two of five residents reviewed. (Residents R8 and R41)

Inspectors wroteBased on reviews of the facility assessment, staff training and competency skill sets to provide care and services to assure residents' safety and ensure that each resident attained or maintained their highest practicable well-being, it was determined that for two of two licensed nursing staff reviewed, the facility failed to have records of training and competencies available for review. (Employees E5 and E27)

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluations were completed for four of four nurse aides reviewed (Employees E24, E25 E26, and E27)

Inspectors wroteBased on review of facility policy, review of employee files, and staff interviews, it was determined that the facility failed to provide training upon hire on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse for thirteen of forty employees reviewed (E11, E12, E15, E16, E17, E18, E19, E20, E21, E31, E32, E33, E34) Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 states, Policy Interpretation and Implementation- The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. [...]

Inspectors wroteBased on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides record reviewed. (Employees E24 and E25).

Inspectors wroteBased on review of clinical records, hospital records,and facility policies and procedures, interviews with staff and residents and review of facility provided incident reports, it was determined that facility failed to ensure a complete evaluation of change in condition to address pain levels for one of 19 residents reviewed (Resident R62).

Inspectors wroteBased on a review of facility policy and procedures, resident group interview, staff interview, and observations it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on two of two nursing units reviewed. (First Floor and Second Floor Units)

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to conduct a significant change assessment for one of nineteen residents reviewed (Resident R28).

Inspectors wroteBased on review of facility provided documentation and review of clinical record, it was determined facility did not ensure to maintain nutrition status according to professional standards of practice for a resident receiving total parenteral nutrition one of 19 residents reviewed. (Resident R71)

Inspectors wroteBased on clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed. (Residents R74) Findings Include: Review of facility policy titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010 states, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: a. how the care plan will be developed and implemented: b. how information will be exchanged between the facilities. Review of Resident R74's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) revealed that the resident was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease. [...]

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of nineteen residents reviewed (Resident R28).

Inspectors wroteBased on reviews of policies and procedures, observations of the outdoor loading and receiving area and interviews with staff, it was determined that the facility was not disposing of garbage and refuse properly.

Inspectors wroteBased on an environmental tour and observations of the food and nutrition services department, interviews with staff and reviews of equipment purchase orders, it was determined that the facility was not maintaining essential equipment for the dietary services department in safe operating condition.

Inspectors wroteBased on observations of the food and nutrition department, reviews of policies and procedures and interviews with staff, it was determined that the facility failed to maintain an an effective pest control program in the dietary department.

Inspectors wroteBased on resident interviews and review of facility policy, it was deteremined that the facility failed to ensure that there was a routine process to ensure that the call bells systems was fincition and that call bells were answered in a timely manner during the weekends on two two nursing floors. (1st and 2nd Floor)

Inspectors wroteBased on review of clinical record and review of facility provided documentation, and interview with staff, it was determined facility failed to ensure complete documentation related to treatment administration for one of three clinical records reviewed. (Resident R1)

Inspectors wroteBased on review of clinical records, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were safely stored for three of three residents reviewed (Resident R3, R4 and Resident R5).

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of two nursing units observed (First and Second floor nursing units).

Inspectors wroteBased on review of facility policy, clinical records reviewed, and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one out of three sampled residents (Resident R1).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on two of two nursing units (First floor and Second floor).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of four residents reviewed for intravenous therapy (Residents R5, R58 and R265).

Inspectors wroteBased on observations, review of the Pennsylvania Nurse Practice Act, clinical record reviews, review of personnel files and interviews with residents and staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for five of five personnel files reviewed for competency evaluations (Employees E11, E12, E13, E14 and E15) and for four of four residents reviewed for intravenous therapy (Residents R5, R58, R265 and R266.)

Inspectors wroteBased on a review of clinical records, review of facility policy and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of three residents reviewed (Resident R16, R5 and R270). Findings Include: Review of the facility policy, Medication Monitoring, Medication Regimen Review (MRR) and Reporting revealed that the Drug Regimen Review is a thorough evaluation of the medication regiment of a resident. And that the resident-specific MRR recommendations and

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for three of five residents reviewed with infections (Residents R5, R16 and R56), infection data reporting and infection committee meetings as required.

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for five of five of residents reviewed for antibiotics (Residents R5, R16, R56, R266 and R265).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required.

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for two of four residents reviewed for intravenous therapy (therapy that delivers liquid substances directly into a vein) (Residents R5 and R58).

Inspectors wroteBased on a review of clinical records, facility policies and documentation, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner, for two of 21resident records reviewed (Residents R16 and R27).

Inspectors wroteBased on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that activities of daily living related to bathing was provided for one out of 26 residents reviewed (Resident R48).

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to obtain and follow physician orders related to diet, urinary catheters and wound care for two of 26 residents reviewed (Residents R168 and R265).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one dialysis residents reviewed (Resident R48).

Inspectors wroteBased on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E16, E17 and E18).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of three residents observed during medication administration. (Resident R220)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to offer pneumococcal vaccines for two of five residents reviewed for vaccinations (Residents R46 and R37).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for 3 out of 25 residents reviewed (Rooms 100,102 and 104)

Inspectors wroteBased on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for five of ten staff reviewed related to training (Employees E20, E18, E11, E14 and E15).

Inspectors wroteBased on interviews, review of clinical records and review of resident grievances, it was determined that the facility failed to provide a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, the date the written decision was issued; and evidence that the resident was notified of the outcome of their grievance for 1 out of 3 residents reviewed (Resident R1):

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to ensure a safe and orderly discharge planning process for five of seven discharge records reviewed. (Resident R1, R2, R3, R4 and R5)

Inspectors wroteBased on reviews of policies and procedures, interviews with staff, review of clinical records and reviewss of hospital records, it was determined that for one of two residents reviewed for weight loss, the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight. (Resident R1)

Inspectors wroteBased on clinical record review, interviews with staff, reviews of the pharmacy delivery schedule, hospital record and policy and procedure reviews, it was determined that the facility failed to acquire and dispense medications as ordered by the physician for one of three residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical records and interview with staff, it was determined that the facility failed to provide resident with measures to prevent the development of or worsening of pressure injury for one of 25 residents reviewed (Resident R59)