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WILLOW GROVE POST ACUTE

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WILLOW GROVE POST ACUTE is a for profit - limited liability company facility in HATBORO, PA with 109 certified beds and a 3-star overall CMS rating. The facility has 50 deficiency records on file.

3485 DAVISVILLE ROAD, HATBORO, PA 19040

Phone: 2158300400

Overall Rating

3/5

Health Inspection

2/5

Staffing

2/5

Quality Measures

5/5

Long-Stay Quality

4/5

Facility Information

Provider Number
396017
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
109
Residents
90
In Hospital
No
County
Montgomery
Last Inspection
May 16, 2025

Staffing Data

RN Hours
1.18 (nat'l avg: 0.68)
LPN Hours
0.56
CNA Hours
1.71
Total Nursing Hours
3.45 (nat'l avg: 3.89)
PT Hours
0.14
Nursing Turnover
67.7%
RN Turnover
62.2%

What the CMS Record Reveals About WILLOW GROVE POST ACUTE

WILLOW GROVE POST ACUTE operates 109 certified beds in HATBORO, PA with approximately 90 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 50 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.45 total nursing hours per resident day (national average 3.89), with RN coverage at 1.18 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, WILLOW GROVE POST ACUTE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 67.7%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (50 most recent)

E — Pattern - Minimal harm Dec 30, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 29, 2026

D — Isolated - Minimal harm Dec 30, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 29, 2026

D — Isolated - Minimal harm Dec 1, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Jan 6, 2026

E — Pattern - Minimal harm Dec 1, 2025 Tag: 0585

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.

Category: Resident Rights Deficiencies

Corrected: Jan 6, 2026

E — Pattern - Minimal harm May 16, 2025 Tag: 0947

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Category: Nursing and Physician Services Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0943

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Category: Environmental Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0908

Keep all essential equipment working safely.

Category: Environmental Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0814

Dispose of garbage and refuse properly.

Category: Nutrition and Dietary Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0730

Observe each nurse aide's job performance and give regular training.

Category: Nursing and Physician Services Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0726

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.

Category: Nursing and Physician Services Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0710

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Category: Nursing and Physician Services Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0637

Assess the resident when there is a significant change in condition

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0585

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.

Category: Resident Rights Deficiencies

Corrected: Jul 8, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0580

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Category: Resident Rights Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0574

The resident has the right to receive notices in a format and a language he or she understands.

Category: Resident Rights Deficiencies

Corrected: Jul 8, 2025

E — Pattern - Minimal harm Dec 9, 2024 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Jan 21, 2025

D — Isolated - Minimal harm Dec 9, 2024 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 21, 2025

E — Pattern - Minimal harm Sep 9, 2024 Tag: 0924

Put firmly secured handrails on each side of hallways.

Category: Environmental Deficiencies

Corrected: Oct 16, 2024

E — Pattern - Minimal harm Sep 9, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Oct 16, 2024

D — Isolated - Minimal harm Sep 9, 2024 Tag: 0584

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.

Category: Resident Rights Deficiencies

Corrected: Oct 16, 2024

D — Isolated - Minimal harm Sep 9, 2024 Tag: 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Category: Resident Rights Deficiencies

Corrected: Oct 16, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0940

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Category: Administration Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0883

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Category: Infection Control Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Aug 15, 2024 Tag: 0881

Implement a program that monitors antibiotic use.

Category: Infection Control Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Aug 15, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Aug 15, 2024 Tag: 0756

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Category: Pharmacy Service Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0730

Observe each nurse aide's job performance and give regular training.

Category: Nursing and Physician Services Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Aug 15, 2024 Tag: 0726

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.

Category: Nursing and Physician Services Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Aug 15, 2024 Tag: 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0655

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Aug 15, 2024 Tag: 0623

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Category: Resident Rights Deficiencies

Corrected: Oct 2, 2024

D — Isolated - Minimal harm Jun 10, 2024 Tag: 0585

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.

Category: Resident Rights Deficiencies

Corrected: Jul 30, 2024

D — Isolated - Minimal harm May 7, 2024 Tag: 0660

Plan the resident's discharge to meet the resident's goals and needs.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 6, 2024

D — Isolated - Minimal harm Apr 27, 2024 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 24, 2024

D — Isolated - Minimal harm Mar 6, 2024 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Apr 23, 2024

D — Isolated - Minimal harm Nov 8, 2023 Tag: 0943

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 4, 2024

D — Isolated - Minimal harm Nov 8, 2023 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Jan 4, 2024

D — Isolated - Minimal harm Nov 8, 2023 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Jan 4, 2024

D — Isolated - Minimal harm Nov 8, 2023 Tag: 0697

Provide safe, appropriate pain management for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 4, 2024

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 16.1% Yes
Percentage of long-stay residents who lose too much weight Long Stay 6.4% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.8% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 12.5% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 0.8% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 61.2% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 37.9% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.3% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 12.2% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 23.3% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 88.5% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 51.2% No
Percentage of long-stay residents with pressure ulcers Long Stay 10.0% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 25.2% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 27.7% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for WILLOW GROVE POST ACUTE?
WILLOW GROVE POST ACUTE has an overall CMS rating of 3 out of 5 stars. This rating combines health inspection results (2★), staffing levels (2★), and quality measures (5★).
What are the staffing levels at WILLOW GROVE POST ACUTE?
WILLOW GROVE POST ACUTE reports 3.45 total nursing hours per resident day (national average: 3.89). RN hours are 1.18 per resident day (national average: 0.68). Nursing staff turnover is 67.7%.
How many beds does WILLOW GROVE POST ACUTE have?
WILLOW GROVE POST ACUTE has 109 certified beds with approximately 90 residents. The facility is located at 3485 DAVISVILLE ROAD, HATBORO, PA 19040.
Does WILLOW GROVE POST ACUTE have any deficiencies on record?
Yes, WILLOW GROVE POST ACUTE has 50 deficiencies on record from recent inspections. Most deficiencies are classified as no harm or minimal harm.
Has WILLOW GROVE POST ACUTE received any fines or penalties?
No, WILLOW GROVE POST ACUTE has no fines or penalties on record.
Who owns WILLOW GROVE POST ACUTE?
WILLOW GROVE POST ACUTE is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was WILLOW GROVE POST ACUTE last inspected?
The most recent health inspection for WILLOW GROVE POST ACUTE was on May 16, 2025. The facility received a health inspection rating of 2 out of 5 stars.
What quality measures are tracked for WILLOW GROVE POST ACUTE?
WILLOW GROVE POST ACUTE is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial