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WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (KUTZTOWN, Pennsylvania)

120 TREXLER AVENUE, KUTZTOWN, Pennsylvania 19530

Phone: 6106836220

CMS Overall:3/5

Overview & Bed Count

Certified Beds
140
Avg Residents/Day
134.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Berks
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health2/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityPennsylvania AvgDifference
RN Hours per Resident per Day0.520.78-0.26
Total Nurse Hours per Resident per Day3.453.90-0.45
CMS Staffing Rating2/53.1/5-
Nursing Staff Turnover39.7%44.6%-

Health Citation History

7 health citations on record

DateCategoryDescriptionSeverity
2026-06-18Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G – Actual Harm
2026-03-27Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.J – Immediate Jeopardy
2026-03-27Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.F – Moderate Harm Potential
2026-03-27Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2026-03-27Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-03-15Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2024-03-15Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.C – Minimal Harm Potential

Fire Safety Citation History

19 fire safety citations on record

DateCategoryDescriptionSeverity
2025-02-07Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2025-02-07Construction DeficienciesMeet other general requirements.E – Moderate Harm Potential
2025-02-07Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2024-03-15Smoke DeficienciesHave properly installed hallway dispensers for alcohol-based hand rub.E – Moderate Harm Potential
2024-03-15Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2024-03-15Smoke DeficienciesEnsure that corridors are separated from use areas by walls constructed to limit the passage of smoke.E – Moderate Harm Potential
2024-03-15Services DeficienciesInstall properly constructed and protected linen or trash chutes.E – Moderate Harm Potential
2024-03-15Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.E – Moderate Harm Potential
2024-01-23Smoke DeficienciesHave a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.F – Moderate Harm Potential
2024-01-23Smoke DeficienciesFollow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.E – Moderate Harm Potential
2023-03-16Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-03-16Construction DeficienciesInstall a two-hour-resistant firewall separation.E – Moderate Harm Potential
2023-03-16Egress DeficienciesHave stairways and smokeproof enclosures used as exits that meet safety requirements.E – Moderate Harm Potential
2023-03-16Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2023-03-16Services DeficienciesInstall properly constructed and protected linen or trash chutes.E – Moderate Harm Potential
2023-03-16Construction DeficienciesMeet other general requirements.C – Minimal Harm Potential
2023-03-16Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.C – Minimal Harm Potential
2023-03-16Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.C – Minimal Harm Potential
2023-03-16Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.C – Minimal Harm Potential

Total Penalties & Fines

$8,281
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2026-03-27Fine$8,281-

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