Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbrooke Ct Skilled Care Buckingham's Choice during CMS and state inspections, most recent first.
Inaccurate MDS coding was identified for multiple residents when assessments failed to capture high-risk medications such as anticonvulsants, hypoglycemics, and antiplatelets, as well as injections, PRN pain meds, falls, and hospice services. The MDS coordinator confirmed several errors, including missed coding for Gabapentin, Metformin, Aspirin, RSV and Prevnar injections, documented falls, and hospice care, while one staff member stated he was not aware Gabapentin was an anticonvulsant.
The facility failed to ensure required physician visits occurred for three residents. One resident admitted recently had no physician note for a required monthly interval during the first 90 days, another resident had a long gap between physician visits despite needing visits at least every 60 days, and a third resident had missing physician documentation in the chart with long gaps between recorded physician encounters. The DON confirmed the missed visit intervals and noted issues with how physician notes were being uploaded into the record.
Incorrect Oxygen Flow Rate: A resident with chronic respiratory failure, COPD, CHF, Afib, aphasia, and late onset Alzheimer's disease was observed receiving oxygen at 3.5 L via nasal cannula even though the physician's order specified 2 L. The TAR showed staff documenting 2 L each shift, and an LPN confirmed the concentrator was actually set at 3.5 L. The DON stated she was aware of the issue and believed the concentrator was not working properly.
The facility failed to keep complete and accurate medical records for two residents. One resident on hospice had no hospice notes in the chart after the last documented entry, even though the hospice nurse and hospice GNA were reportedly visiting regularly. Another resident reported a broken upper left tooth and had been seen by dental providers, but the chart had no dental visit notes when reviewed by the surveyor.
The facility inaccurately coded MDS assessments for several residents, misidentifying grab bars as restraints and incorrectly documenting a fall injury. Observations and interviews revealed a misunderstanding in coding practices, impacting the accuracy of resident assessments.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as hearing aid assistance, pain management, chronic constipation, and the use of grab bars. A resident with impaired hearing did not receive necessary assistance with hearing aids, while another resident's pain management needs were not formally addressed in a care plan. Additionally, a resident with chronic constipation and another using grab bars for mobility lacked appropriate care plans, highlighting gaps in the facility's care planning process.
The facility failed to deliver food at appropriate temperatures, as observed during a test tray temperature check. Breakfast items were served below the standard temperature due to the use of an open steel cart for transportation, which was chosen because closed carts were too heavy. This issue was noted during breakfast service for the Skilled Nursing Unit, with the Regional CDM confirming the inappropriate practice.
A surveyor found expired and unlabeled food items in the Skilled Nursing Unit kitchen, confirmed by staff. The Regional CDM was informed, and the facility planned to implement inspection reports to ensure proper food storage. The NHA and DON were notified.
A resident at high risk for wandering eloped from a facility due to inadequate door security. The resident exited through an unlocked door not part of the skilled unit, despite the Wander Guard system in place. The door alarm sounded, but the resident was found outside by security, having sustained a minor injury. Interviews revealed the door locked from the outside but not the inside, contributing to the incident.
The facility failed to conduct quarterly care plan meetings and update care plans for two residents. One resident's family was not invited to meetings, and documentation was lacking. Another resident's care plan was outdated, inaccurately reflecting a previous condition. The Registered Dietitian confirmed the care plan was not updated to reflect the current condition.
Inaccurate MDS Coding for Medications, Injections, Falls, Pain, and Hospice
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for multiple residents during the recertification/complaint survey. The deficiencies involved inaccurate coding of high-risk drug classes, injections, pain management, falls, and hospice services across several assessments. The MDS is part of the Resident Assessment Instrument and is used to identify each resident’s individual needs and guide care planning based on those needs. For Resident #21, the January 2026 MDS failed to capture Metformin, which was administered every morning and evening for diabetes, and Gabapentin, which was given three times per day. Staff #3, the MDS coordinator, stated he was not aware that Gabapentin was an anticonvulsant and confirmed the errors. For Resident #1, the October 2025 MDS failed to capture Gabapentin as an anticonvulsant and failed to capture the Abrysvo RSV vaccine injection in Section N0300; the January 2026 MDS also failed to capture Gabapentin in Section N0415. For Resident #19, the October 2025 MDS failed to capture Aspirin as an antiplatelet drug, failed to capture the RSV vaccine injection, and failed to code PRN pain medication use after Naproxen was given for pain. The January 2026 MDS for the same resident also failed to capture Aspirin and failed to code PRN Tylenol and Naproxen use. Additional inaccuracies were identified for Resident #7, whose November 2025 MDS failed to capture Gabapentin and Metformin in Section N0415, and Resident #22, whose admission MDS failed to capture a Prevnar injection in Section N0300. Resident #5’s quarterly MDS coded no for falls despite a documented fall with injury, Resident #16’s annual MDS coded one fall despite two documented falls, and Resident #30’s significant change MDS coded no for hospice care despite admission to hospice. The MDS coordinator confirmed the errors for these residents, and the DON was informed of the MDS concerns.
Missed Required Physician Visits
Penalty
Summary
The facility failed to ensure that the attending physician saw residents at the required intervals for three reviewed residents. Resident #14, who was admitted to the facility on [DATE], had physician notes showing visits on 7/18/25 and 8/22/25, but no physician note for September 2025 and the next note was not until 10/23/25. The DON confirmed on 2/13/26 that Resident #14 was not seen every 30 days during the first 90 days after admission. Resident #16, who had been admitted in 2022, had physician notes in 2025 showing a visit on 4/24/25 and then no further visit until 9/25/25. The DON confirmed on 2/13/26 that Resident #16 was not seen every 60 days in 2025. Resident #9, admitted in August 2021, had physician notes uploaded into the electronic record dated 1/20/25, with no other physician notes in the record until a 9/15/25 visit; there were no physician visits in the paper record, and after 9/15/25 there were no other physician visits until 12/18/25. The DON stated that it was unusual that there were no notes in the system, that two staff members switched the task of uploading physician notes, and later stated she had found another physician note dated 2/17/25 that had been sent from the physician’s office.
Incorrect Oxygen Flow Rate
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who had diagnoses including chronic respiratory failure with hypoxia, COPD, atrial fibrillation, acute diastolic CHF, aphasia, and late onset Alzheimer's disease. The resident was observed on two occasions receiving oxygen via nasal cannula at 3.5 L, while the February 2026 physician's order specified oxygen at 2 liters per minute. The resident's January 2026 physician note documented chronic respiratory failure, oxygen after COVID in 2020, and intermittent upper airway wheezing not responsive to steroids. The resident's care plans addressed altered cardiovascular status and altered respiratory status, with interventions including oxygen use per physician order and administration of medications/inhalers as ordered. However, the February 2026 TAR showed nurses signing off every shift that the resident was receiving oxygen at 2 liters per minute, not 3.5 liters per minute. When asked, an LPN stated the resident was supposed to be receiving 2 liters and then confirmed the concentrator was set at 3.5 liters. The DON stated she was aware of the issue and believed the oxygen concentrator was not working properly, so it was switched out and the resident was given another one.
Incomplete Medical Records for Hospice and Dental Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for 2 residents reviewed during the survey. For one resident admitted to hospice services in September 2025, the medical record contained no hospice notes after 10/22/25 when the record was reviewed by the DON, even though the hospice nurse later provided multiple hospice nurse and hospice GNA notes dated from late October 2025 through early February 2026. The DON confirmed those hospice notes were not in the resident’s medical record at the time of review, and the hospice nurse stated she visited the resident once or twice a week and the hospice GNA twice a week. For another resident, the surveyor learned during interview that the resident had a broken upper left tooth and had been seen by someone in the facility and by an outside dentist, but the medical record contained no dental visit notes for 2025 or 2026 when reviewed. The DON stated she was not aware the resident reported a broken tooth and initially confirmed there were no dental notes in the record. The DON later obtained notes from a facility dental visit and an outside dental visit, confirming those provider notes were not present in the resident’s medical record at the time of the survey review.
Inaccurate MDS Coding for Restraints and Fall Injuries
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, specifically regarding the use of 1/8 grab bars and the status of a resident after a fall. For five residents, the MDS assessments inaccurately identified bedrails as physical restraints, despite physician orders and care plans indicating their use as mobility aids. Observations confirmed the use of grab bars for mobility, yet the MDS records incorrectly documented them as restraints. Additionally, the facility inaccurately coded a resident's fall incident in the MDS assessment. The resident experienced a fall resulting in a skin tear, but the discharge MDS assessment inaccurately recorded the incident as having no injury. The MDS nurse acknowledged the error, indicating reliance on incident reports and related documentation for coding, which led to the oversight. Interviews with the MDS Coordinator and the Director of Nursing revealed a misunderstanding in coding practices, as they believed no residents were on restraints and that bedrails were used solely for mobility. The Director of Nursing was informed of the inaccuracies, highlighting a need for accurate assessment and documentation to ensure proper resident care.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #233, who was admitted with impaired hearing, was observed having difficulty hearing due to the lack of assistance with hearing aids. Although the resident's baseline care plan noted a communication problem related to hearing deficit, it did not include specific interventions for the use of hearing aids, which was confirmed by the Director of Nursing (DON) as a necessary inclusion. Resident #230 reported experiencing back pain that was relieved by Tylenol, yet there was no care plan developed to address this pain management need. The resident's clinical record showed the administration of Gabapentin and Tylenol for pain, but the absence of a formal care plan for pain management was acknowledged by the DON. Similarly, Resident #5 had a history of chronic constipation and was receiving medications like MiraLAX and Colace, but this condition was not included in the resident's care plan, as confirmed by the Assistant Director of Nursing (ADON). Additionally, Resident #23 was using bilateral grab bars for bed mobility and repositioning, as indicated in the resident's orders and MDS assessments. However, there was no care plan developed to address the use of these grab bars until after surveyor intervention. The MDS Coordinator stated that care plans should be created when a Care Area Assessment (CAA) is triggered, but this was not done for Resident #23 until the deficiency was pointed out by the surveyor.
Inadequate Food Temperature Control
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during an observation of a test tray temperature, which revealed that the food was not at the correct temperature when served. Specifically, the cream chipped beef was measured at 110.4°F, and the cream of wheat was at 123.9°F, both of which are below the standard serving temperature. The cold milk was at 41°F, which was within the acceptable range. The issue was observed during the breakfast service for the Skilled Nursing Unit, where the meal schedule was not adhered to, resulting in a delay in serving breakfast. The deficiency was attributed to the method of transporting the food trays from the Assisted Living kitchen to the Skilled Nursing Unit. The trays were initially placed in an open steel cart, which was not appropriate for maintaining the food temperature. The staff used the open cart because the closed carts were reportedly too heavy to transport between floors. This practice was confirmed by the Regional Certified Dietary Manager, who was temporarily assisting the facility due to the recent resignation of the facility's Certified Dietary Manager. The deficiency was reported to the Nursing Home Administrator and the Director of Nursing during the exit conference.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store and label food items in the Skilled Nursing Unit kitchen, as observed during an initial tour by a surveyor. The surveyor, assisted by a staff member, found four cartons of fat-free chocolate milk that were expired and confirmed by the staff. Additionally, five unlabeled and undated white paper cups containing ice cream were found in another refrigerator. These findings were confirmed by the staff member, who then discarded the items. The Regional Certified Dietary Manager (CDM) was informed of these findings and acknowledged the issue. She was temporarily covering the position until a new CDM was hired. The surveyor was later provided with documents indicating that the facility would implement an Opening Inspection Report and a Closing Inspection Report to ensure proper food storage practices. The Nursing Home Administrator and the Director of Nursing were made aware of the findings during the exit conference.
Elopement Incident Due to Inadequate Door Security
Penalty
Summary
The facility failed to provide a safe environment to prevent an elopement incident involving a resident identified as being at high risk for wandering. The incident occurred when the resident, who had a history of cognitive impairment and was assessed as a high risk to wander, managed to exit the skilled unit through a door that was not part of the unit and had no lock. The resident was found outside on the facility campus by security after the door alarm had sounded, indicating a breach in the facility's wandering management system. The wandering management system in place, known as Wander Guard, is designed to alert staff when a resident wearing a bracelet approaches a monitored door. However, the system's effectiveness was compromised as the door used by the resident to exit was not equipped with a lock from the inside, allowing the resident to leave the premises. The alarm system did alert staff, but the resident was able to exit the building and was found outside, where they sustained a minor injury. Interviews with staff revealed that the door leading to the Independent Living area locked from the outside but not from the inside, which contributed to the resident's ability to elope. The facility's Director of Nursing confirmed that the double doors of the skilled unit would lock but not alarm if closed, and the door used by the resident was not adequately secured to prevent such incidents. This oversight in the facility's security measures led to the resident's elopement and subsequent fall outside the facility.
Failure to Conduct Quarterly Care Plan Meetings and Update Care Plans
Penalty
Summary
The facility failed to conduct quarterly care plan meetings and to review and revise interdisciplinary care plans accurately for two residents. For one resident, family members reported not being invited to any care plan meetings, and documentation revealed only one meeting in the past year, despite the requirement for quarterly meetings. The Social Service Coordinator confirmed that meetings should be documented in the Electronic Medical Record, but only one sign-in sheet was provided, indicating a lack of consistent documentation and communication with the resident's family. Another resident was readmitted with several diagnoses, including constipation and dysphagia, and was receiving speech therapy and dietary assessments. However, the care plan in the clinical record was outdated, reflecting a previous condition of bilateral lower extremity edema that was no longer present. The Registered Dietitian confirmed the care plan was not updated to reflect the resident's current condition, as the system automatically pulled in old information. This oversight resulted in an inaccurate care plan that did not address the resident's current needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Adamstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederick Crossing Of Journey | 6.4 mi | ★★★★★ | 38 | 0 |
| Autumn Lake Healthcare At Braddock Heights | 7 mi | ★★★★★ | 3 | 0 |
| Northampton Manor Nursing And Rehabilitation Cente | 7.9 mi | ★★★★★ | 26 | 0 |
| Citizens Care And Rehabilitation Center Of Frederi | 7.9 mi | ★★★★★ | 16 | 0 |
| Autumn Lake Healthcare At Ballenger Creek | 8.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.