Willow Brook Rehab: Narcotic Count Failures on All Carts - PA
Not occasionally. Not on one cart. On all six.
Federal inspectors reviewing controlled substance logs for January, February, and March 2026 found the same pattern repeated across Unit I and Unit II, each with three medication carts operating without automated dispensing systems. In January, there was no documented evidence of shift counts on 15 of 31 days. In February, 14 of 28 days. In March, inspectors reviewed records through the 24th of the month and found gaps on 11 of those 24 days. Across all three months, roughly half the days reviewed had no verified narcotic count on record.
The facility's own policy, last reviewed as recently as February 26, 2026, spelled out the requirement plainly: two licensed nurses were to account for all controlled substances at the end of each shift on carts without automated systems. The nurse coming on and the nurse going off were both to sign the Shift Count Log, confirming the count was done and the numbers were clean.
The signatures were not there.
Willow Brook's Director of Nursing confirmed the requirement in an interview with inspectors on March 25. Two days later, on March 27, the Director of Nursing confirmed again, this time more directly: there was no evidence the controlled substances had been counted and signed off on the identified dates, and there should have been.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, and noted that many residents were affected, given that the failures ran across all six carts serving the facility's two units.
What the logs cannot show is what, if anything, happened to the narcotics on the days nobody checked. That is precisely the point of a shift count. Two nurses verifying the same number, shift after shift, creates a paper trail that makes diversion or error detectable. When the count does not happen, or when it happens and no one signs the log, that trail disappears. A discrepancy on a day with no documented count would be, by definition, undiscoverable after the fact.
The inspection covered three months of records and found the gaps running in roughly equal proportion across all three, suggesting this was not a rough patch or a staffing crisis on a single unit. January was worse by count, but February and March were not recoveries. The rate of missed documentation held.
Inspectors cited violations of Pennsylvania nursing home regulations governing both pharmacy services and nursing services.
The facility's plan of correction was not included in the inspection report. For information on how Willow Brook intends to address the deficiency, the report directs readers to contact the nursing home or the state survey agency directly.
Willow Brook Rehabilitation and Healthcare Center is located at 120 Trexler Avenue in Kutztown.
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.
In January, there was no documented evidence of shift counts on 15 of 31 days.
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.