Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Willowcrest during CMS and state inspections, most recent first.
Improper food storage and labeling were observed in the kitchen. Surveyors found multiple cheeses that were undated or missing use-by dates, opened and exposed sliced cheese, soup bags without thaw or pull dates, uncovered roast beef, and raw turkey that was undated and leaking fluid. In the freezer, shrimp had ripped-open packaging with exposed product and freezer burn, and food was stored with poultry above shrimp and beef above vegetables, creating a cross-contamination concern.
Failure to Provide Written Transfer Notice: A resident was transferred to the hospital for shortness of breath, but the record did not show that the resident or the resident’s representative received written notice of the transfer or the reason for the move in a language and manner they understood. The facility administrator confirmed that written transfer notices were not part of facility practice.
A resident’s care plan was not revised after a therapy assessment identified ADL, bed mobility, cognitive, and safety limitations and recommended specific positioning and fall-prevention measures. The resident later fell out of bed while using a bed pan, and the DON confirmed there was no documented evidence that the care plan had been reviewed and updated to reflect the new interventions related to the fall.
A resident with a recent stroke, left-sided weakness, aphasia, and significant pain was not given appropriate toileting assistance when she said she needed to use the toilet. An aide placed the incontinent resident on a bedpan even though she normally did not use one, left her there while she cried out in pain, and the resident later fell out of bed onto the floor. The resident’s son reported she said, "Bedpan hurt," and the DON stated she had been trying to get off the bedpan and could not find the call bell.
Failure to follow a physician order for multipodus boots for a resident with fractures, foot drop, and moderate cognitive impairment. Staff were unsure of the order details, the resident was observed wearing a sneaker and leg brace instead of the ordered boots, and the record did not document that the boots were ever provided or worn.
Failure to Evaluate Significant Weight Gain: A resident’s admission wt was not entered into the system, and a later wt showed an 11.38% gain over 5 days compared with the admission wt. The RD did not reference the admission wt, no rewt was completed to verify accuracy, and the significant wt change was not addressed or evaluated by the nutrition services team.
The facility failed to provide accessible grievance forms and an option for anonymous submissions. During a resident group interview, three alert and oriented residents reported not knowing how to file grievances anonymously or where to find grievance forms. An observation confirmed the absence of accessible grievance forms or a grievance box on the 3rd floor. The Unit Coordinator stated that grievance forms were stored in a filing cabinet accessible only to employees, with no grievance box available for anonymous submissions.
A facility failed to maintain effective infection control for a resident with COVID-19 on enhanced respiratory precautions. A nurse did not remove PPE after exiting the resident's room, contrary to policy, and continued to wear the same gown while preparing medications and walking in the hallway. This was confirmed by observations and staff interviews.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation of the main kitchen with the Food Service Director, an employee, and the Chef, surveyors found multiple food items improperly labeled, undated, uncovered, or stored in a manner that could lead to contamination. In the main refrigerator, blue cheese was undated, additional blue cheese had no use-by date, Monterey cheese had no date, some cheese had use-by dates of 12/12 and 12/30, other cheese was undated, mild cheddar slices were opened, exposed, and undated, and Swiss cheese was opened and undated. Surveyors also observed three bags of beef vegetable soup without thaw or pull dates, approximately 70 lbs. of roast beef stored uncovered, and raw turkey leaking red fluid and undated. In the main freezer, shrimp was found in ripped-open packaging with exposed product and freezer burn, and it was stored on the lowest rack with poultry above it and beef above vegetables, creating a cross-contamination concern. The Food Service Director and Chef confirmed these findings during the kitchen tour.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative received written notice of a transfer and the reason for the move in writing and in a language and manner they understood. Review of Resident R50’s medical record showed that the resident was admitted to the hospital on December 11, 2025 for shortness of breath. The record review did not reveal documentation that the resident or the resident’s representative was given written notification of the transfer or the reasons for the move. During interview on January 5, 2026, the facility administrator confirmed the finding and stated that it was not facility practice to provide residents and/or their representatives with written notice for transfers.
Failure to Update Care Plan After Therapy Assessment and Fall
Penalty
Summary
The facility failed to review and revise a resident care plan with new interventions after a fall-related event for Resident R24. A therapy note dated November 20, 2025, documented impairments and limitations in ADLs, bed mobility, cognition, decreased knowledge of condition and precautions, and safety awareness, and noted the resident tended to favor the left side. Therapy also notified nursing staff to use a wedge pillow with a dycem mat on the left side in bed and a fall mat on the right side, but the resident’s care plan was not revised to include these interventions. The clinical record further showed that on December 9, 2025, a nursing note documented Resident R24 in bed using the bed pan when the resident fell out of bed onto the floor. During interviews, the DON stated that after the fall the new intervention was for staff to stand nearby while the resident was being toileted. The DON later confirmed there was no documented evidence that the facility reviewed and revised the resident’s care plan based on the therapist assessment and that the care plan did not address the new interventions related to the fall.
Failure to Provide Appropriate Toileting Assistance
Penalty
Summary
The facility failed to ensure an incontinent resident who was unable to perform activities of daily living received appropriate toileting assistance. Resident R24 had a history of traumatic intracranial hemorrhage and a right MCA stroke in October 2025, leaving left-sided weakness and pain. OT documented impaired safety/judgment and communication deficits, including dysarthria and aphasia. Therapy notes also described severe pain with gentle stretching, dependence for bed mobility, and profound left-sided pain with light touch and repositioning. Speech therapy later noted the resident appeared to be in pain, needed repositioning, and required assistance to use the call button. During a speech therapy session, the resident stated she needed to use the toilet, but the nursing aide told the therapist she could go and be changed after. The aide then placed the resident on a bedpan, although she normally did not use one and was incontinent. The aide reported the resident cried out in pain when being positioned on the bedpan and was left there with the call bell on her stomach for 5 to 10 minutes. When the aide returned, the resident had fallen out of bed onto the floor. The resident’s son later reported she repeatedly said, "Bedpan hurt, bedpan hurt," and the DON stated the resident had been trying to get off the bedpan and could not find the call bell, which was hanging off the bed after the fall.
Failure to Follow Physician Order for Multipodus Boots
Penalty
Summary
The facility failed to ensure care and treatment were provided in accordance with physician orders for one resident who was admitted with diagnoses including fractures and foot drop and who had a BIMS score of nine, indicating moderate cognitive impairment. A physician order dated December 1, 2025, directed use of multipodus boots to the resident's left foot drop, but the order did not specify parameters for use such as duration, timing, or conditions for application. During interview, a registered nurse stated the resident was not wearing the ordered boots because she did not like them and said the nurse was unfamiliar with the specific order details or when the boots were to be applied. Observation showed the resident at bedside wearing a sneaker and leg brace, with no multipodus boots present in the room or readily available. A physical therapy manager later stated the resident was using a leg brace and sneaker as part of a therapy trial and was unsure of the specific physician order requirements related to the multipodus boots. Follow-up communication confirmed the boots were intended to be worn at night, and the clinical record did not show documentation that the resident was provided or wore the multipodus boot at any time.
Failure to Evaluate Significant Weight Gain
Penalty
Summary
The facility failed to assess and implement interventions to ensure acceptable nutritional status for Resident R16. Review of the facility’s Height and Weight Protocol showed that residents’ admission weight and height are to be recorded, and residents with a weekly weight gain or loss of five pounds are to be re-weighed. Resident R16’s clinical record showed an admission weight of 94 pounds, but the Registered Dietitian stated that this weight was not transcribed into the system and was not referenced by the nutrition services team when evaluating weight changes. The record further showed that Resident R16 was documented at 104.7 pounds five days later, an 11.38% or 10.7-pound weight gain compared with the admission weight. Despite this significant change, no reweight was completed to confirm the accuracy of the weight, and the weight gain was not addressed or evaluated by the nutrition services team. Review of the record did not show reconciliation of the conflicting weights or confirmation of an accurate baseline weight, and follow-up interviews with the RD staff confirmed the failure to identify and investigate the significant weight change.
Grievance Form Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents and did not provide an opportunity for anonymous grievances to be submitted. This deficiency was identified during a resident group interview with three alert and oriented residents who reported being unaware of how to file grievances anonymously and not knowing the location of grievance forms. An observation on the 3rd floor confirmed the absence of grievance forms or a grievance box accessible to residents. An interview with the Unit Coordinator revealed that grievance forms were kept in a filing cabinet only accessible to employees, and there was no grievance box available for residents to submit grievances anonymously.
Inadequate Adherence to Respiratory Precautions for COVID-19 Resident
Penalty
Summary
The facility failed to maintain an effective infection control program related to respiratory precautions for a resident diagnosed with COVID-19. The resident, identified as R122, was on enhanced respiratory precautions, which required staff to don appropriate personal protective equipment (PPE) such as an N95 mask, gown, gloves, and eye protection before entering the resident's room. Observations revealed that a licensed nurse, Employee E3, did not adhere to these protocols. Employee E3 donned the required PPE before entering the resident's room but failed to remove the gown and gloves upon exiting, as mandated by the facility's policy. Instead, Employee E3 continued to wear the same gown while preparing medications outside the resident's room and walked in the hallway to obtain a clean pair of gloves. This action was contrary to the infection control policy, which required the removal and disposal of the gown and gloves before exiting the room. Interviews with the infection control manager and nurse confirmed the requirement for staff to remove and discard PPE before leaving the room of a resident on enhanced respiratory precautions. This deficiency was identified during a medication observation and was corroborated by interviews with the involved staff.
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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 Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Philadelphia Protestant Home | 0.5 mi | ★★★★★ | 11 | 0 |
| Willow Terrace | 1.5 mi | ★★★★★ | 9 | 0 |
| Maplewood Nursing And Rehab Center | 1.6 mi | ★★★★★ | 17 | 0 |
| Laurel Square Healthcare And Rehabilitation Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Independence Rehab And Nursing | 1.7 mi | ★★★★★ | 44 | 1 |
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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.