WILLOW GROVE POST ACUTE
3485 DAVISVILLE ROAD, HATBORO, PA 19040 · CCN 396017
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 109
- Avg residents/day
- 90.1
- Phone
- 2158300400
Inspection history vs Pennsylvania & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Pennsylvania avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-05-16 | 20 | 10.1 | 9.5 | +9.9 worse |
| 2 | 2024-08-15 | 26 | 10.9 | 9.8 | +15.1 worse |
| 3 | 2023-11-08 | 14 | 10.5 | 9.3 | +3.5 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 5 |
| Resident assessment and care planning | 2 |
| Nursing and physician services | 4 |
| Resident rights | 4 |
| Nutrition and dietary | 1 |
| Environmental | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.45 | 67.7% |
| RN staffing (reported) | 1.18 | 62.2% |
| Total nurse staffing (adjusted) | 3.24 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- MARQUIS HEALTH SERVICES
- Facilities in chain
- 81
- Chain avg overall
- 3.00 / 5
Inspection citations (60)
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-12-30 · Health · corrected 2026-01-29
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-12-30 · Health · corrected 2026-01-29
Potential for more than minimal harm
- EF0585Honor 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.2025-12-01 · Health · corrected 2026-01-06
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2025-12-01 · Health · corrected 2026-01-06
Potential for more than minimal harm
- EF0574The resident has the right to receive notices in a format and a language he or she understands.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0585Honor 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.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0637Assess the resident when there is a significant change in condition2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0730Observe each nurse aide's job performance and give regular training.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0814Dispose of garbage and refuse properly.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0908Keep all essential equipment working safely.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-05-16 · Health · corrected 2025-07-08
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-12-09 · Health · corrected 2025-01-21
Potential for more than minimal harm
- EF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-12-09 · Health · corrected 2025-01-21
Potential for more than minimal harm
- DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2024-09-09 · Health · corrected 2024-10-16
Potential for more than minimal harm
- DF0584Honor 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.2024-09-09 · Health · corrected 2024-10-16
Potential for more than minimal harm
- EF0761Ensure 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.2024-09-09 · Health · corrected 2024-10-16
Potential for more than minimal harm
- EF0924Put firmly secured handrails on each side of hallways.2024-09-09 · Health · corrected 2024-10-16
Potential for more than minimal harm
- DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- EF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- EF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0730Observe each nurse aide's job performance and give regular training.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- EF0881Implement a program that monitors antibiotic use.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0940Develop, implement, and/or maintain an effective training program for all new and existing staff members.2024-08-15 · Health · corrected 2024-10-02
Potential for more than minimal harm
- DF0585Honor 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.2024-06-10 · Health · corrected 2024-07-30
Potential for more than minimal harm
- DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-05-07 · Health · corrected 2024-07-06
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2024-04-27 · Health · corrected 2024-06-24
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-03-06 · Health · corrected 2024-04-23
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0697Provide safe, appropriate pain management for a resident who requires such services.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0761Ensure 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.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2023-11-08 · Health · corrected 2024-01-04
Potential for more than minimal harm
- DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-08-25 · Health · corrected 2023-09-15
Potential for more than minimal harm
- EF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-03-29 · Health · corrected 2023-05-09
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| WILLOW GROVE HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2025-01-01 |
| NFR 2020 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| QUINTO NEXGEN LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| RSBRMK HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| SK NEXGEN TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| UAK 2020 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| UKR NEXGEN LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| YK NEXGEN TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-14 |
| TRAN, DEREK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| WALLER, JULIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| WALLER, JULIE | Individual | CORPORATE DIRECTOR | — | 2025-01-01 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER | — | 2025-01-01 |
| MANUFACTURERS & TRADERS TRUST COMPANY | Organization | 5% OR GREATER SECURITY INTEREST | — | 2025-01-01 |
| MANUFACTURERS & TRADERS TRUST COMPANY | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2025-01-01 |
Other facilities in HATBORO
| Name | Overall | Beds |
|---|---|---|
| LUTHER WOODS NURSING AND REHABILITATION CENTER | ★★★★☆ | 140 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.