The facility's own policy requires medication carts to remain "closed and locked when out of sight of the medication nurse." Yet inspectors documented multiple violations across both nursing floors within hours.
On the second floor at 9:41 a.m. on December 31, inspectors found a medication cart completely unlocked with the narcotic book open and a resident's photograph and information displayed on the computer screen. No nurse was present.
Licensed nurse Employee E4 had left the cart unattended to deliver pain medication to a resident "a few rooms down," she told inspectors when they located her three minutes later. A second cart sat unlocked nearby with only a cellphone on top.
When asked about moving carts between rooms, Employee E4 said: "They don't move the carts here from room to room, but I can if you want me to I can." She explained she had been reassigned to a different unit that day and was confused about which residents were hers. After counting her census sheet, she confirmed responsibility for 29 residents.
At 10:25 a.m., Employee E4 asked an inspector if the cellphone left on the second medication cart belonged to her. The nurse confirmed that cart was also unlocked and was hers as well.
Minutes earlier at 10:21 a.m., inspectors observed another dangerous practice. Licensed nurse Employee E3 left her medication cart to enter a resident's room empty-handed, then emerged carrying a medication cup containing several pills.
Employee E3 told inspectors she had gone to crush one resident's medication while waiting for another resident to take their pills. The medication cart was positioned two rooms away on the opposite side of the hallway from where she was working.
"When asked if this was standard practice the nurse stated that it was not," inspectors wrote. Employee E3 was responsible for 31 residents on the day shift and was still completing her morning medication rounds.
The problems extended beyond the second floor. At 11:01 a.m., inspectors found an unlocked medication cart on the first floor with resident information visible on the computer screen.
Licensed nurse Employee E5 arrived two minutes later to lock the cart and close the computer screen. When asked whether leaving carts unlocked with screens visible was normal practice, she said it was not.
The facility's April 2019 medication policy explicitly states that carts may only be positioned "in the doorway of the resident's room, with open drawers facing inward and all other sides closed." The policy requires carts to remain "clearly visible to the personnel administering medications" with "all outward sides inaccessible to residents or others passing by."
The policy also prohibits keeping medications on top of carts, yet inspectors found personal items like cellphones left on the equipment.
Federal inspectors determined the facility failed to prevent accidents and hazards related to unattended medication carts on both nursing units they reviewed. The violations affected some residents and created minimal harm or potential for actual harm.
The investigation revealed systemic problems with medication security protocols. Nurses left controlled substances exposed, patient information accessible to unauthorized individuals, and medication carts vulnerable to tampering or theft.
One nurse's confusion about her patient assignments highlighted staffing coordination issues that contributed to unsafe practices. With nurses responsible for 29 to 31 residents each during day shift, the pressure to complete medication rounds appeared to override safety protocols.
The facility's policy requires medications to be administered "in a safe and timely manner, and as prescribed." Yet the observed practices created opportunities for medication errors, theft of controlled substances, and privacy violations.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent hazards. The repeated instances of unattended medication carts with exposed narcotics and patient data violated these fundamental safety requirements.
The inspection findings demonstrate how basic security protocols broke down across multiple nursing units, creating risks that extended far beyond the immediate medication administration process.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Grove Post Acute from 2025-12-30 including all violations, facility responses, and corrective action plans.