Federal Nursing-Home Survey Record
WILLOW GROVE POST ACUTE
Does WILLOW GROVE POST ACUTE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), WILLOW GROVE POST ACUTE (CCN 396017), in HATBORO, PA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 22 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-05-16. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.0
Deficiency timeline — full federal history
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide enough food/fluids to maintain a resident's health.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
The resident has the right to receive notices in a format and a language he or she understands.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Observe each nurse aide's job performance and give regular training.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Dispose of garbage and refuse properly.
Assess the resident when there is a significant change in condition
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Provide enough food/fluids to maintain a resident's health.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Keep all essential equipment working safely.
38 citations from earlier inspection cycles — historical, not current (expand)
Make sure that a working call system is available in each resident's bathroom and bathing area.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Put firmly secured handrails on each side of hallways.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Ensure that residents are fully informed and understand their health status, care and treatments.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Observe each nurse aide's job performance and give regular training.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Ensure medication error rates are not 5 percent or greater.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Plan the resident's discharge to meet the resident's goals and needs.
Provide enough food/fluids to maintain a resident's health.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Respond appropriately to all alleged violations.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate pain management for a resident who requires such services.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure each resident receives an accurate assessment.
Document what happened
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