Willow Grove Post Acute: Unlocked Medication Carts - PA
That was the scene inspectors documented at Willow Grove Post Acute on December 31, 2025, during a complaint inspection of the facility's two nursing units. By the time the morning was over, three separate nurses on two floors had left medication carts unlocked and unattended, with resident information exposed and narcotics accessible to anyone passing through the hallway.
The nurse at the center of the first incident, identified in the report as Employee E4, was not near her cart when inspectors spotted it at 9:41 a.m. on the second floor. Three minutes later, a second cart sat unlocked just to the right of the first, with only a cellphone resting on top. At 9:46, E4 returned and explained herself: she had gone a few rooms down to give a resident pain medication and hadn't moved the cart with her. When asked why, she said nurses don't move carts from room to room on that unit, then added, "but I can if you want me to I can."
She also said she had been moved to the unit that morning and was confused about which residents she was responsible for. After counting her census sheet, she arrived at 29.
At 10:25 a.m., E4 approached the surveyor and asked whether a cellphone left on the second cart was hers. It was not. She then confirmed that the second cart was also hers, and that it, too, had been left unlocked.
The second incident unfolded a few minutes earlier, at 10:21 a.m., when inspectors observed Employee E3 at her medication cart, then watched her walk away from it empty-handed into a resident's room. She came out carrying a medication cup with several pills inside. Her explanation: she had gone to crush a roommate's medication while waiting for the first resident to take hers. The cart was two rooms away on the opposite side of the hallway. When asked whether that was standard practice, E3 said it was not. She was in the middle of morning medication pass and was assigned 31 residents for the day shift.
On the first floor, at 11:01 a.m., inspectors found a third cart unlocked, with resident information still displayed on the screen. Two minutes later, Employee E5 arrived, locked the cart, and closed the screen. Asked whether it was normal to leave it that way, E5 said it was not.
The facility's own written policy, dated April 2019, is explicit. Medication carts must be locked when out of sight of the nurse administering medications. No medications are to be kept on top of the cart. All outward sides must be inaccessible to residents or others passing by. The narcotic log sitting open on an unattended cart, the unlocked drawers, the resident photographs left on screen — none of it was consistent with what the policy requires.
The inspection covered both nursing units and cited the failures as affecting some residents on each floor. The level of harm was classified as minimal harm or potential for actual harm, the lower end of the federal scale, but the pattern across three nurses, two floors, and a single morning raises a different question: how many mornings the surveyor was not there.
A nurse responsible for 31 residents completing morning medication pass alone, walking away from an unlocked cart to crush a pill in a room two doors down, is not making a reckless choice so much as an impossible one. The carts stayed where they were. The medications moved without them.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WILLOW GROVE POST ACUTE in HATBORO, PA was cited for violations during a health inspection on December 30, 2025.
That was the scene inspectors documented at Willow Grove Post Acute on December 31, 2025, during a complaint inspection of the facility's two nursing units.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.