Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW GROVE POST ACUTE
HATBORO, PA · 109 certified beds · Last Life Safety survey May 15, 2026
CMS Certification Number 396017 · first certified January 1997
Ownership
Operated by MARQUIS HEALTH SERVICES · For profit - Limited Liability company
- New ownershipOwnership changed January 1, 2025 (change of ownership)from 3485 DAVISVILLE ROAD OPERATIONS II LLC
Position within PA
28 citations — more than 93% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 7.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was May 2026. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
- F-0924 Put firmly secured handrails on each side of hallways.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 19, 2024 | 2 |
| August 15, 2024 | 5 |
| May 16, 2025 | 15 |
| May 15, 2026 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-05-16 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2026-05-15 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-05-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-05-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2026-05-15 |
| K-0161 | Use approved construction type or materials. | 1 | 2026-05-15 |
| K-0906 | Ensure gas cylinders are properly stored. | 1 | 2024-08-15 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-08-15 |
What the citations cover
- Smoke Deficiencies 10
- Emergency Preparedness Deficiencies 7
- Services Deficiencies 3
- Construction Deficiencies 2
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Emergency Preparedness Deficiencies | 7 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 15, 2026 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 24, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 24, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 24, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 24, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 24, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 24, 2026) |
May 16, 2025 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 14, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 14, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (July 14, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (July 14, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (July 14, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (July 14, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 14, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 14, 2025) |
August 15, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0233 | Install resident room doors of proper design and width. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0906 | Ensure gas cylinders are properly stored. | Deficient, Provider has date of correction (October 2, 2024) |
January 19, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 2, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 2, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.