Willow Grove Post Acute
WILLOW GROVE POST ACUTE in HATBORO, PA — inspection on December 30, 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.
Inspection Findings
administering medications in a timely and consistent manner.
Per patient's sister request, this nurse
Details-Patient complained her medication was late.
Further review of the grievance form revealed
medications were late, but she then got to administer the medications as soon as she could.
Resolved Note- Nurse will be verbally educated on giving residents medications in a timely manner. 28 Pa Code 211.12(d)(1) Nursing services
396017 12/30/2025
Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040
Review of policy states, Policy Statement Medications are administered in a safe and timely manner, and as prescribed.
Further review of facility policy revealed Policy Interpretation and Implementation- .20.
During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart.
The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
Observation on the second floor on December 31, 2025 revealed a licensed nurse Employee E4 not observed around the medication cart assigned to them at 9:41 a.m.
The medication cart had the narcotic book out and open, the medication cart was unlocked, resident information was up on the computer screen including the photograph. A second cart was observed at 9:44 a.m. to the right of the first nursing cart also unlocked with just a cellphone on top of the cart. At 9:46 a.m. the medication cart that was unlocked was identified a licensed nurse Employee E4 stated, the resident a few rooms down was having pain so I went to them to administer the pain medication.
When asked the licensed nurse Employee E4 stated, they don't move the carts here from room to room, but I can if you want me to I can.
The licensed nurse stated that she got moved units so there was confusion on what residents she had.
When asked how many residents the licensed nurse was assigned to they stated 29 after counting the census sheet. At 10:25 a.m. licensed nurse Employee E4 asked the surveyor if a cellphone left on the second medication was hers and she stated no.
The licensed nurse Employee E4 confirmed that the other cart was also left unlocked and that it was her cart as well.
Further observation on the second hall on the second-floor nursing unit revealed licensed nurse Employee E3 was seen observed at 10:21 a.m. at the medication cart.
Once the surveyor passed Resident R5's room, Employee E3 was observed leaving the medication cart and going into Resident R5's room empty handed and walking out with a medication cup in hand containing several pills.
When asked the licensed nurse Employee E3 stated that she went to crush R5's roommate Resident 4's medication while she was waiting for Resident R5 to take her medication.
The medication cart was located two rooms down from Resident R5's room on the opposite side of the hallway.
When asked if this was standard practice the nurse stated that it was not.
When asked how many residents the licensed nurse had today Employee E3 counted the census sheet and was assigned 31 residents for day shift and at the time was still completing morning medication pass.
Observation of the first-floor nursing unit at 11:01 a.m. revealed a medication cart which was left unlocked with the resident information up on the computer. At 11:03 a.m. licensed nurse R5 came to the medication cart to lock it and close the screen on the computer.
When asked if it was normal practice to leave the cart unlocked and screen visible the licensed nurse Employee E5 stated it is not. 28 Pa.
Code 201.14(a) Responsibility of licensee28 PA.
Code 211.12(d)(1)(5) Nursing services
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.