Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
GARDEN SPRING REHAB AND CARE CENTER
WILLOW GROVE, PA · 173 certified beds · Last Life Safety survey October 18, 2024
CMS Certification Number 395077 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
- Ownership changed July 1, 2019 (change of ownership)to GARDEN SPRING NURSING AND REHABILITATION CENTER from GARDEN SPRING CENTER SNF LLC
Position within PA
7 citations — more than 35% 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 0 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to October 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was October 2024. 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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Emergency preparedness
7 of the 7 citations on file are Emergency Preparedness E-tags — every citation here is about the program, not the building. 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)
9 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 7 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 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.
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 | 7 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 2, 2022 | 5 |
| November 16, 2023 | 2 |
| October 18, 2024 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | 2 | 2023-11-16 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2022-12-02 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2022-12-02 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2022-12-02 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2023-11-16 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2022-12-02 |
What the citations cover
- Emergency Preparedness Deficiencies 7
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 7 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 16, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 13, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (January 13, 2024) |
December 2, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 14, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (February 14, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (February 14, 2023) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (February 14, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (March 18, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.