C78

WILLOW GROVE POST ACUTE

Grade C 78/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
3/5
Health Insp.
2/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

109

Ownership

For profit - Limited Liability company

Total Fines

None

Last Survey

N/A

3485 DAVISVILLE ROAD, HATBORO, PA 19040
2158300400

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.11h
LPN
0.52h
CNA
1.60h
Total
3.24h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WILLOW GROVE HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2025

100%

NFR 2020 IRRV TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

QUINTO NEXGEN LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

RSBRMK HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

SK NEXGEN TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

TRYKO NEXGEN HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

UAK 2020 IRRV TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

UKR NEXGEN LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

YK NEXGEN TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2025

MARQUIS LIMITED LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

RELIANT PRO REHAB LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

TRAN, DEREK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

WALLER, JULIE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

WALLER, JULIE

IndividualCORPORATE DIRECTORSince Jan 2025

POSEN, MINDEE

IndividualCORPORATE OFFICERSince Jan 2025

MANUFACTURERS & TRADERS TRUST COMPANY

Organization5% OR GREATER SECURITY INTERESTSince Jan 2025

MANUFACTURERS & TRADERS TRUST COMPANY

Organization5% OR GREATER MORTGAGE INTERESTSince Jan 2025

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (58)

December 1, 2025Health2 deficiencies
0585EMinimal harm, Pattern

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.

Resident Rights Deficiencies

0919DMinimal harm, Isolated

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

Environmental Deficiencies

May 16, 2025Health16 deficiencies
0574EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Jul 8, 2025
0580DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Jul 8, 2025
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jul 8, 2025
0637DMinimal harm, Isolated

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Corrected Jul 8, 2025
0657EMinimal harm, Pattern

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

Resident Assessment and Care Planning Deficiencies

Corrected Jul 8, 2025
0690EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jul 8, 2025
0692DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 8, 2025
0698DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 8, 2025
0710DMinimal harm, Isolated

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

Nursing and Physician Services Deficiencies

Corrected Jul 8, 2025
0726EMinimal harm, Pattern

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.

Nursing and Physician Services Deficiencies

Corrected Jul 8, 2025
0730EMinimal harm, Pattern

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

Nursing and Physician Services Deficiencies

Corrected Jul 8, 2025
0814DMinimal harm, Isolated

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Jul 8, 2025
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Jul 8, 2025
0925DMinimal harm, Isolated

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

Environmental Deficiencies

Corrected Jul 8, 2025
0943EMinimal harm, Pattern

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 8, 2025
0947EMinimal harm, Pattern

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

Nursing and Physician Services Deficiencies

Corrected Jul 8, 2025
December 9, 2024Health2 deficiencies
0842DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 21, 2025
0919EMinimal harm, Pattern

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

Environmental Deficiencies

Corrected Jan 21, 2025
September 9, 2024Health4 deficiencies
0552DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Oct 16, 2024
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 16, 2024
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Oct 16, 2024
0924EMinimal harm, Pattern

Put firmly secured handrails on each side of hallways.

Environmental Deficiencies

Corrected Oct 16, 2024
August 15, 2024Health16 deficiencies
0623DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Oct 2, 2024
0655DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Oct 2, 2024
0656DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Oct 2, 2024
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 2, 2024
0694EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Oct 2, 2024
0698DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 2, 2024
0726EMinimal harm, Pattern

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.

Nursing and Physician Services Deficiencies

Corrected Oct 2, 2024
0730DMinimal harm, Isolated

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

Nursing and Physician Services Deficiencies

Corrected Oct 2, 2024
0756EMinimal harm, Pattern

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

Pharmacy Service Deficiencies

Corrected Oct 2, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 2, 2024
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Oct 2, 2024
0883DMinimal harm, Isolated

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

Infection Control Deficiencies

Corrected Oct 2, 2024
0919DMinimal harm, Isolated

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

Environmental Deficiencies

Corrected Oct 2, 2024
0940DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Oct 2, 2024
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 2, 2024
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Oct 2, 2024
June 10, 2024Health1 deficiency
0585DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Jul 30, 2024
May 7, 2024Health1 deficiency
0660DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jul 6, 2024
April 27, 2024Health1 deficiency
0692DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jun 24, 2024
March 6, 2024Health1 deficiency
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Apr 23, 2024
November 8, 2023Health12 deficiencies
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jan 4, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 4, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 4, 2024
0656DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 4, 2024
0657DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 4, 2024
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 4, 2024
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 4, 2024
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 4, 2024
0697DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 4, 2024
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Jan 4, 2024
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jan 4, 2024
0943DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 4, 2024
August 25, 2023Health1 deficiency
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Sep 15, 2023
March 29, 2023Health1 deficiency
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected May 9, 2023

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Frequently Asked Questions

What is the CareGrader rating for WILLOW GROVE POST ACUTE?

WILLOW GROVE POST ACUTE in HATBORO, Pennsylvania has a CareGrader grade of C (Average), with a composite score of 77.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WILLOW GROVE POST ACUTE?

WILLOW GROVE POST ACUTE has an overall CMS star rating of 3 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WILLOW GROVE POST ACUTE have?

WILLOW GROVE POST ACUTE has 58 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does WILLOW GROVE POST ACUTE have?

WILLOW GROVE POST ACUTE has 109 certified beds with approximately 90 current residents (83% occupancy). The facility is located at 3485 DAVISVILLE ROAD, HATBORO, Pennsylvania 19040. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.