The Willow Grove personal-care home shut down by the state after two residents died there in the last two weeks was understaffed, and medication was dispensed by unlicensed employees, according to Department of Public Welfare records.
Those are just two items on a long list of DPW violations for Willow Crest Manor.
The state agency found that medicines given to residents weren't recorded, so there was no way to know whether they were receiving the right amount. Often they weren't.
One patient was supposed to get medicine twice daily, but got one dose in six days. Another told staff he needed insulin, and when they didn't give it to him, he injected himself while unsupervised.
Some received recalled medications, while others got pills without doctor's orders, according to DPW. The home failed to get lab work done for one person and did not report when another fell and needed to go to the hospital.
In the summer, owner Anand P. Mittal was accused of choking a Parkinson's patient.
"We have been in the process of trying to shut it down, but there were court injunctions and all sorts of filings by his attorney," said DPW spokeswoman Stacey Witalec.
Forty-eight residents, most of them with mental-health problems, were moved out of the Fitzwatertown Road residence on Thursday after the deaths on Nov. 28 and last Saturday of a 24-year-old man and a 48-year-old woman. Witalec said one died "under suspicious circumstances," but she didn't elaborate.
One patient had open, weeping ulcers and the other was not given Medrol as prescribed by a doctor to treat bronchitis and asthma, according to DPW reports. Witalec declined to identify the dead residents, citing privacy laws.
Three people remained at Willow Crest yesterday, unable or unwilling to leave the troubled facility.
Eric J. Yankovich, the brother of one resident, called the state's move against Willow Crest Manor "an obscenity."
"I saw people being taken out against their will," he said while visiting his sister at the home, which had a skeleton staff on duty to care for the patients.
Mittal, who goes by the name David and lives in Lower Gwynedd, said the families of those left behind insisted that they stay.
Others wanted to remain, he said, but he could keep only three since DPW, which ordered the shut-down, does not have jurisdiction over a home with up to three people.
He said he did not want to comment on the charges against him or the violations at his homes.
The agency has cracked down on serious problems at Mittal's other facilities, Southampton Manor in Bucks County and Diston Manor and Adelphia in Philadelphia, according to DPW. Mittal is appealing a ban of his license at Adelphia.
DPW records show the agency first intervened at Willow Crest in November 2005, when Mittal was given a six-month provisional license.
Violations continued and, a year later, he was denied a request to increase the home's capacity. In April 2007, Mittal was ordered to comply with the current capacity and a month later "major fiscal issues" were identified.
In July 2007, Mittal was given his third provisional license and cited for more violations, including lack of minimal staffing. The report also says a doctor whose signature was on a resident's medical exam denied that the signature was his.
After reaching a settlement with DPW the following November, Mittal was allowed to increase the number of beds from about 50 to 95.
In January, DPW did not renew his license and banned new admissions. Following another settlement, Mittal was required to hire an independent administrator and undergo independent medication audits.
Celeste Delano Dyson was hired as the administrator in June. Not long after, the staff started telling her stories.
"All sorts of things - bad medications, mistreating people," said Dyson, who lives in Bucks County and has worked in assisted living for 14 years.
She soon realized, she said, that the facility wasn't top-notch. Sections were old and run-down, there were few activities for the residents, and the staff was poorly trained, she said. Some of them even stole from residents, Dyson said.
Then, on the afternoon of Aug. 29, an employee told her she had seen Mittal put his hands around the neck of 74-year-old Donald Powell for 20 to 30 seconds when the man knocked on a locked door to get into the lobby.
"I'd never seen anything like this," Dyson said.
She called DPW and Upper Moreland Police, which charged Mittal with assault, harassment and disorderly conduct. The case is pending in Montgomery County. As a condition of his bail, Mittal was not allowed to enter any of his properties, Witalec said.
Dyson worked at the facility for one more week, but quit because of what she thought was retaliation.
Mittal, a pharmacist who supplied his patients with medicines, said he did not want to comment on the charges against him or the violations at his homes.
Yankovich, of Warminster, had nothing but good things to say about Mittal and Willow Crest. His sister, Anne, 60 and diagnosed with paranoid schizophrenia, has lived in five or six other homes in Philadelphia and none were as good as Willow Crest, he said.
"When she's in a normal, happy mood she loves this place," he said, adding that the grounds were nice, the staff was good, and the activities were plentiful.
"You don't know what a relief it is," he said.
Another resident staying behind, Nancy Aruhly, 52, who has lived at Willow Crest for four years, said she was also very happy there.
"I don't know what I would do without Willow Crest," she said.