Willow Brook Rehab: Medication Order Failures - PA
The violations involved three residents and stretched across two months. In each case, the physician's order was clear. In each case, staff didn't follow it. In none of the cases was a physician notified.
Resident 22 had diabetes and chronic kidney disease. Her orders required staff to check her blood sugar before each insulin dose and hold the medication if the reading dropped below 120 milligrams per deciliter. The instruction existed for a reason: giving insulin to someone whose blood sugar is already low can push it lower still, causing shakiness, confusion, loss of consciousness, or worse. In February 2026, staff gave her insulin glargine once when her blood sugar was below that threshold. In March, they did it three more times. They also administered insulin aspart twice in March under the same conditions. The Director of Nursing confirmed to inspectors on March 27 that staff were supposed to hold the insulin when the blood sugar was below 120.
Resident 70 was being treated for hypotension, or low blood pressure, with a drug called midodrine, which works by constricting blood vessels to raise pressure. The order was specific: do not give this medication if the resident's systolic blood pressure exceeds 120 millimeters of mercury. Giving a blood pressure-raising drug to someone whose pressure is already elevated carries its own risks. Staff gave it to Resident 70 anyway, once in February and seven more times in March, each time with a systolic reading above the cutoff. The Director of Nursing confirmed that Resident 70 should not have received midodrine under those conditions.
The situation for Resident 14 was different in kind but similar in consequence. This resident had end stage renal disease and depended on dialysis to survive. Because of a related condition, hypotension, a physician had ordered midodrine once daily at 9:00 a.m., every Monday, Wednesday, and Friday. A separate order, in place since November 2025, required staff to have the resident ready to leave the facility at 5:30 a.m. on those same three days for dialysis appointments.
The conflict between those two orders was never resolved. Resident 14 was gone before the 9:00 a.m. dose could be given. In February, staff recorded six missed doses because the resident was out of the building. In March, they recorded eleven. No one contacted the prescribing physician to report the missed doses. No one adjusted the administration schedule to account for the dialysis departure time. The orders simply sat in conflict, and the medication went ungiven, week after week.
The Director of Nursing told inspectors that when a medication cannot be administered, the nurse responsible is expected to contact the physician by the following day. She confirmed that no such contact was documented for Resident 14 across either month.
Seventeen missed doses over two months. No call to the doctor.
The inspection covered 28 residents. Three had physician orders that weren't followed. The facility's own Director of Nursing, in each instance, confirmed what the records showed.
Willow Brook Rehabilitation and Healthcare Center is located at 120 Trexler Avenue in Kutztown. The inspection was completed March 27, 2026. The report does not describe any harm that resulted from the missed or contraindicated doses. It does not say whether Resident 14's hypotension worsened on dialysis days without the medication, or whether Resident 22's blood sugar dropped to a level requiring intervention after the insulin was given. Those details are not in the record.
What is in the record is that no one called the doctor, and no one changed the schedule, and the doses kept getting missed or given wrong for two months running.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Brook Rehabilitation and Healthcare Center from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER in KUTZTOWN, PA was cited for violations during a health inspection on March 27, 2026.
The violations involved three residents and stretched across two months.
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.