Commonwealth Senior Living at Willow Grove.

“Suspected abuse allegation was not reported to the local area agency on aging. On 10/28/25, resident #1 reported feeling threatened and scared by staff member A, and local police were called, but the facility failed to report this suspected abuse to the local area agency on aging as required.”

“When an allegation of abuse involving a staff person occurred, the home did not immediately develop and implement a plan of supervision or suspend the staff member involved. Following the 10/28/25 incident between resident #1 and staff member A, no supervision plan or suspension was implemented until during the survey.”

“An incident report for an altercation on 10/28/25 between resident #1 and staff member A was not submitted to the Department within 24 hours; it was submitted on 10/30/25 at 8:30 AM instead of the required timeframe.”

“A staff laptop displaying personal resident information was found open, unlocked, unattended, and accessible on a medication cart on the first floor. This is a repeat violation from 03/24/25.”

“The resident-home contract for resident #3 was not signed by the resident, as required. The contract must be signed by the administrator or designee, the resident, and the payer if different from the resident.”

“Uncovered pans of eggs, pancakes, bacon, sausage, and oatmeal were stored in a heating table in the kitchen, and three red plates of prepared servings were uncovered and accessible with no staff present, exposing food to potential contamination.”

“Computers on medication carts were unlocked, unattended, and open to the medication administration program, revealing resident medical information on the 3rd and 2nd floors. A yellow resident assignment book containing resident hygiene information and a red binder with resident care summaries were also unlocked and accessible on medication carts.”

“During the 11 PM to 7 AM shift, two staff members had a physical altercation in the home with loaded firearms present. Staff brought handguns into the facility, consumed alcohol and smoked during the shift, and one staff member carried hot water with intent to throw it at the other. A resident in the SDCU who wanders at night was potentially exposed to these dangerous conditions. Both staff members were terminated.”

“Multiple cameras were placed throughout the facility recording resident room hallways, medication carts, common living rooms, and common dining areas where residents were visible. No signs were posted indicating that video recording was in progress, violating resident privacy rights. Only recording of entrances, exits, and interior corridors leading to entrances/exits is permitted with proper signage and resident notification.”

“A direct care staff person was hired but did not have a criminal history background check requested until after the hire date, in violation of criminal history check requirements.”

“Two direct care staff persons did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, failing to meet required qualifications for direct care staff.”

“A red STOP sign sticker was adhered to the 3rd floor fire exit stairway door, creating a possible obstruction by deterring persons from using that emergency exit in an event of emergency.”

“The home failed to submit an incident report to the Department within 24 hours regarding alleged neglect of a resident who did not receive morning care (bathing, dressing, grooming, incontinence care) and was found in a saturated incontinence brief at 11:20 AM.”

“The resident-home contract for Resident #2 does not include a statement signed by the resident and the resident's designated person at the time of admission, informing the resident that rent rebate information will be kept in the resident's record.”

“The home has not implemented its quality management plan as required, having failed to conduct a quality management review as stated in the home's policy to be conducted yearly.”

“A resident requiring assistance with bowel/bladder management was not treated with dignity and respect. A bedside commode was found full with feces and urinals containing urine at 10:45 AM, approximately 5+ hours after staff last assisted at 5:15 AM. Staff frequently failed to empty the commode after bowel movements and urinals, with the resident reporting waits of up to 5 hours for assistance.”

“Direct care staff person B did not receive required annual training in medication self-administration and instruction on meeting resident needs as described in preadmission screening forms, assessment tools, medical evaluations and support plans during training year 2023.”

“Staff person C did not receive required annual training in fire safety, emergency preparedness procedures, resident rights, Older Adult Protective Services Act, and falls and accident prevention during training year 2023. Staff person D did not receive required annual training in emergency preparedness procedures, resident rights, Older Adult Protective Services Act, and falls and accident prevention during training year 2023.”

“Staff person E did not receive required fire safety and emergency preparedness orientation on their first day of work, including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and emergency services notification.”

“The facility failed to report incidents of abuse to the Department within 24 hours. Staff persons instructed a resident to use an abusive method (removing bed linens and turning on air conditioner full blast) to force compliance with getting out of bed, and physical abuse (gripping and slamming resident against wall) was witnessed but not reported timely.”

“A resident requiring physical assistance with transfers was subjected to abusive practices by staff, including being instructed to remove bed linens and turn on air conditioning to force the resident out of bed, and physical abuse involving gripping and slamming the resident against the wall.”

“Residents were not treated with dignity and respect. Staff instructed caregivers to use a method involving removal of bed linens and exposure to cold air to force a non-compliant resident out of bed, and a resident was physically abused by being gripped and slammed against a wall.”