Willow Grove Post Acute
3485 Davisville Road, Hatboro, PA 19040
Willow Grove Post Acute is a nursing home in Hatboro, Pennsylvania. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (215) 830-0400
- Last standard health inspection
- May 15, 2026 (5 months ago)
- Certified beds
- 109
- Residents per day, on average
- 96.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Willow Grove Operator LLC
- Chain
- Marquis Health Services
- Takes part in
- Medicare and Medicaid
More health citations than the Pennsylvania average (56 vs 31).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
7 citations
Health inspection on May 15, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on June 17, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0677 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0684 3 times since 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0686 2 times since 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0689 2 times since 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 17, 2026.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on June 17, 2026.
CMS has cited this home for F0908 2 times since 2025.
6 citations
Fire safety inspection on May 15, 2026
CMS lists this as a standard inspection.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 24, 2026.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on June 24, 2026.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 24, 2026.
CMS has cited this home for K0353 2 times since 2024.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on June 24, 2026.
CMS has cited this home for K0355 2 times since 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 24, 2026.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 24, 2026.
CMS has cited this home for K0712 2 times since 2025.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
2 citations
Health inspection on March 17, 2026
CMS lists this as a complaint inspection.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 17, 2026.
CMS has cited this home for F0692 3 times since 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 17, 2026.
CMS has cited this home for F0842 2 times since 2024.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
2 citations
Health inspection on December 30, 2025
CMS lists this as a complaint inspection.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 29, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 29, 2026.
2 citations
Health inspection on December 1, 2025
CMS lists this as a complaint inspection.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 6, 2026.
CMS has cited this home for F0585 3 times since 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on January 6, 2026.
CMS has cited this home for F0919 3 times since 2024.
CMS update of November 20, 2025
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
Staffing
Total nurse staffing reported to CMS went from 4.5 to 4.0 hours per resident per day.
Health citation
CMS removed citation F0623 from the health inspection on August 15, 2024.
CMS update of May 28, 2025
Name
CMS lists a new legal business name for this home.
16 citations
Health inspection on May 16, 2025
CMS lists this as a standard inspection.
Citation F0574. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
The resident has the right to receive notices in a format and a language he or she understands.
CMS lists it as corrected on July 8, 2025.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 8, 2025.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 8, 2025.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 8, 2025.
CMS has cited this home for F0726 2 times since 2024.
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on July 8, 2025.
CMS has cited this home for F0730 2 times since 2024.
Citation F0943. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on July 8, 2025.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on July 8, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 8, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 8, 2025.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on July 8, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 8, 2025.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on July 8, 2025.
CMS has cited this home for F0698 2 times since 2024.
Citation F0710. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
CMS lists it as corrected on July 8, 2025.
Citation F0814. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on July 8, 2025.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on July 8, 2025.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on July 8, 2025.
15 citations
Fire safety inspection on May 16, 2025
CMS lists this as a standard inspection.
Citation K0100. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on July 14, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 14, 2025.
CMS has cited this home for K0345 2 times since 2024.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on July 14, 2025.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 14, 2025.
Citation K0342. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on July 14, 2025.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on July 14, 2025.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on July 14, 2025.
CMS has cited this home for K0521 2 times since 2024.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 14, 2025.
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on July 14, 2025.
Citation E0006. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on July 14, 2025.
Citation E0022. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for sheltering.
CMS lists it as corrected on July 14, 2025.
Citation E0025. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on July 14, 2025.
Citation E0026. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on July 14, 2025.
Citation E0030. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on July 14, 2025.
Citation E0031. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on July 14, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Name
CMS lists a new name for this home. It was ACCELERATE SKILLED NURSING AND REHABILITATION WILL.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
2 citations
Health inspection on December 9, 2024
CMS lists this as a complaint inspection.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on January 21, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on January 21, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
4 citations
Health inspection on September 9, 2024
CMS lists this as a complaint inspection.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 16, 2024.
Citation F0924. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Put firmly secured handrails on each side of hallways.
CMS lists it as corrected on October 16, 2024.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on October 16, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 16, 2024.
16 citations
Health inspection on August 15, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0694. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on October 2, 2024.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 2, 2024.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on October 2, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 2, 2024.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on October 2, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on October 2, 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on October 2, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 2, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 2, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 2, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on October 2, 2024.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on October 2, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 2, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on October 2, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on October 2, 2024.
Citation F0940. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on October 2, 2024.
5 citations
Fire safety inspection on August 15, 2024
CMS lists this as a standard inspection.
Citation K0233. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install resident room doors of proper design and width.
CMS lists it as corrected on October 2, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 2, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on October 2, 2024.
Citation K0906. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure gas cylinders are properly stored.
CMS lists it as corrected on October 2, 2024.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 2, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on June 10, 2024
CMS lists this as a complaint inspection.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2024.
1 citation
Health inspection on May 7, 2024
CMS lists this as a complaint inspection.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on July 6, 2024.
1 citation
Health inspection on April 27, 2024
CMS lists this as a complaint inspection.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 24, 2024.
CMS update of March 28, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
1 citation
Health inspection on March 6, 2024
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 23, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.1 to 3.7 hours per resident per day.
2 citations
Fire safety inspection on January 19, 2024
CMS lists this as a complaint inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 2, 2024.
Citation K0521. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on March 2, 2024.
1 citation
Health inspection on November 8, 2023
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 4, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WILLOW GROVE HOLDCO LLC5% or greater direct ownership interest · 100% · since 01/01/2025
- ROKEACH, FRAIDEIndirect ownership interest · not applicable · since 01/01/2025
- MARQUIS LIMITED LLCOperational/managerial control · not applicable · since 01/01/2025
- RELIANT PRO REHAB LLCOperational/managerial control · not applicable · since 01/14/2025
- TRAN, DEREKOperational/managerial control · not applicable · since 01/01/2025
- WALLER, JULIEOperational/managerial control · not applicable · since 01/01/2025
Questions
When was Willow Grove Post Acute last inspected?
CMS lists May 15, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Willow Grove Post Acute have?
CMS lists 56 health citations since November 8, 2023. CMS also calls these deficiencies.
Has Willow Grove Post Acute been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Willow Grove Post Acute?
Its CMS overall star rating is 3 of 5.
Is Willow Grove Post Acute a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.