Willow Grove Post Acute
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
medication pass. Review of the facility grievance log revealed a grievance for Resident Resident R9 dated November 10, 2025 stated, Grievance Details- Patient's sister complained he did not receive his meds on time. Further
review of the grievance form revealed that, Summary of findings- There was a delay in medication administration. Resolved Note- Education will be provided to the nurse regarding the importance of administering medications in a timely and consistent manner. Per patient's sister request, this nurse will no longer be assigned to the patient's room. No further concerns at this time. Review of facility grievance log revealed a grievance for Resident Resident R10 dated September 21, 2025 stated, Grievance Details-Patient complained her medication was late. Further review of the grievance form revealed that, Summary of findings- The Nurse was covering another nurse that day. She indicated that 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
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Grove Post Acute
3485 Davisville Road Hatboro, PA 19040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to unattended medication carts and medications for two of two nursing units reviewed. (First floor and Second floor)Findings Include: Review of facility policy titled, Administering Medications dated April 2019. 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 Resident R5's room, Employee E3 was observed leaving the medication cart and going into Resident 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 Resident R5's roommate Resident 4's medication while she was waiting for Resident Resident R5 to take her medication. The medication cart was located two rooms down from Resident 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 Resident 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
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WILLOW GROVE POST ACUTE in HATBORO, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.