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Complaint Investigation

Willow Grove Post Acute

December 1, 2025 · Hatboro, PA · 3485 Davisville Road
Citations 2
CMS Rating 2/5
Beds 109
Provider ID 396017
Healthcare Facility
Willow Grove Post Acute
Hatboro, PA  ·  View full profile →
Inspection Summary

WILLOW GROVE POST ACUTE in HATBORO, PA — inspection on December 1, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0585
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided documentation, it was determined that the facility failed to address residents' concerns related to late call bell response time three of six residents reviewed. (Resident R3, R4, R5) Findings include:During interview with Resident R3, on Monday, December 1, 2025 at 11:10 am, room [ROOM NUMBER]-A, he reported waiting excessively long time for response from nursing staff during overnight shifts, 11 pm to 7 am.Review of facility provided grievance reports for month of November 2025 revealed care concern was submitted on November 2, 2025 regarding Resident R4, and untimely hygiene care; unidentified shift.Further review of grievance reports revealed care concern was submitted on November 2, 2025, regarding Resident R5 and call bell response time; unidentified shift.Further review of facility report submitted to the State Survey Agency, dated November 18, 2025, revealed Resident R5's concern related to waiting long periods for care, and not cleaned properly after being soiled; unidentified shift.Review of facility provided call bell audits for month of November 2025 revealed that audits were mainly completed during day and evening shifts, unidentified times, and excluding room #'s from which concerns were reported.Further review of call bell audits, dated November 22, 2025, revealed unidentified shift and time, noting one hour wait time for call bell response from 2:30 pm to 3:30 pm. 28 PA Code 201.18(b)(3) Management

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Grove Post Acute

3485 Davisville Road Hatboro, PA 19040

SUMMARY STATEMENT OF DEFICIENCIES

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility provided documentation, interview with residents and observations, it was determined that facility did not ensure that call bells were properly functioning for one of six residents reviewed. (Resident R2) Findings include: Review of facility current policy ‘Answering the Call Light,' indicates that purpose of this procedure is to ensure timely responses to the resident's requests and needs.Further review of policy indicates that staff are to ensure that the call light is plugged in and functioning at all times, and report all defective call lights promptly.During interview with Resident R2 on Monday, December 1, 2025 at 11:30 am, room [ROOM NUMBER]-B, the resident reported that his call bell had not function for a while and did not bother reporting it since (his/her) other concerns were unaddressed as well.Further observation of Resident R2's environment revealed non-functioning call bell system. 28 Pa Code 211.12(d)(1)(5) Nursing services

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HATBORO, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOW GROVE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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