Willow Grove, PA

Garden Spring Rehab And Care Center

2-star overall rating with 2-star inspections with 9 recent health deficiencies

1113 North Easton Road, Willow Grove, PA

(215) 830-5400

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

173

Certified beds

Average residents

131

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Imperial Healthcare Group

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

13 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.46

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.15

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.88

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.26

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.27

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.68

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

72%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,294

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.37

Composite VBP score used to determine payment impact.

Payment multiplier

0.9877

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.83

Baseline 23.97% · Performance 20.27% · Measure score 4.83 · Achievement 2.51 · Improvement 4.83

Healthcare-associated infections

4.10

Baseline 10.66% · Performance 8.05% · Measure score 4.10 · Achievement 0 · Improvement 4.10

Total nurse turnover

3.08

Baseline 75.66% · Performance 57.46% · Measure score 3.08 · Achievement 1.52 · Improvement 3.08

Adjusted total nurse staffing

1.33

Baseline 3.36 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.84%	10.72% 0.9 pts better	No Different than the National Rate · Eligible stays 72 · Observed rate 12.5% · Lower 95% interval 6.97%
Discharge to community	32.51%	50.57% 18.1 pts worse	Worse than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 20.91%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	98.61%	95.27% 3.3 pts better	Numerator 71 · Denominator 72
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 72
Discharge self-care score	56.41%	53.69% 2.7 pts better	Numerator 22 · Denominator 39
Discharge mobility score	41.03%	50.94% 9.9 pts worse	Numerator 16 · Denominator 39
Pressure ulcers or injuries, new or worsened	1.39%	2.29% 0.9 pts better	Numerator 1 · Denominator 72 · Adjusted rate 1.23%
Healthcare-associated infections requiring hospitalization	8.05%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 4.45%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 120
Staff flu vaccination coverage	8.66%	42% 33.3 pts worse	Numerator 20 · Denominator 231
Discharge function score	61.54%	56.45% 5.1 pts better	Numerator 24 · Denominator 39
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 31 · Denominator 31
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	4.65%	25.2% 20.5 pts worse	Numerator 2 · Denominator 43

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.6	1.7 1.9 pts worse	1.9 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.8 · Expected 2.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.2 0.2 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	58.2%	86.9% 28.7 pts worse	93.4% 35.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 58.5% · Q2 52.3% · Q3 59.2% · Q4 62.7% · 4Q avg 58.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	85.4%	93.5% 8.1 pts worse	95.5% 10.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 85.4%
Percentage of long-stay residents experiencing one or more falls with major injury	4.3%	3.2% 1.1 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.9% · Q3 5.4% · Q4 2.4% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.2%	6.5% 0.3 pts better	11.4% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 7.2% · Q4 12.9% · 4Q avg 6.2%
Percentage of long-stay residents who lose too much weight	12.3%	6.5% 5.8 pts worse	5.4% 6.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.7% · Q3 19.7% · Q4 15.9% · 4Q avg 12.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.4%	19.9% 4.5 pts better	19.6% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.0% · Q3 13.8% · Q4 23.5% · 4Q avg 15.4%
Percentage of long-stay residents who received an antipsychotic medication	22.6%	18.7% 3.9 pts worse	16.7% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 22.5% · Q3 22.8% · Q4 28.9% · 4Q avg 22.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.4%	0.2% 0.2 pts worse	0.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents whose ability to walk independently worsened	24.5%	19.6% 4.9 pts worse	16.3% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.3% · Q3 43.3% · Q4 16.0% · 4Q avg 24.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.4%	18.3% 4.9 pts better	14.9% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 16.7% · Q3 16.2% · Q4 9.9% · 4Q avg 13.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.9% 0.3 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.7% 0.5 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.6% · Q3 0.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.6%	26.4% 3.2 pts worse	19.8% 9.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 40.9% · Q3 25.2% · Q4 27.9% · 4Q avg 29.6%
Percentage of long-stay residents with pressure ulcers	8.5%	5.3% 3.2 pts worse	5.1% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.0% · Q3 9.7% · Q4 6.4% · 4Q avg 8.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	12.8%	68.9% 56.1 pts worse	81.7% 68.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 12.4% · Q3 8.9% · Q4 8.7% · 4Q avg 12.8%
Percentage of short-stay residents who had an outpatient emergency department visit	7.0%	9.8% 2.8 pts better	12.0% 5 pts better	Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 9.0% · Expected 14.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.5% 0.3 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 2.7% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	16.7%	68.7% 52 pts worse	79.7% 63 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 16.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.6%	23.1% 2.5 pts worse	23.9% 1.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 34.6% · Expected 32.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-18 · Fire 2024-10-18

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-11-16 · Fire 2023-11-16

12 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 3 Health 2022-12-02 · Fire 2022-12-02

24 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Fire safety

Fire-safety citations

C · Minimal harm 2023-11-16

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-01-13

C · Minimal harm 2023-11-16

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-01-13

B · Minimal harm 2022-12-02

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2023-02-14

B · Minimal harm 2022-12-02

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-03-18

B · Minimal harm 2022-12-02

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-02-14

B · Minimal harm 2022-12-02

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2023-02-14

B · Minimal harm 2022-12-02

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2023-02-14

Inspection history

Recent health citations

K · Immediate jeopardy 2025-11-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-09

E · Potential for more than minimal harm 2025-07-11

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-08-12

D · Potential for more than minimal harm 2025-07-11

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-12

D · Potential for more than minimal harm 2025-07-11

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-12

D · Potential for more than minimal harm 2025-07-11

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-12

D · Potential for more than minimal harm 2025-07-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-12

D · Potential for more than minimal harm 2024-10-18

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-11-07

C · Minimal harm 2024-10-18

F623 · Resident Rights Deficiencies

Health

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

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-02

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-30

D · Potential for more than minimal harm 2024-08-08

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-07-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-07-29

D · Potential for more than minimal harm 2024-07-12

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-29

D · Potential for more than minimal harm 2024-06-17

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2024-06-25

C · Minimal harm 2024-02-27

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-03-13

E · Potential for more than minimal harm 2023-11-16

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-16

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-16

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-16

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-16

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-11-16

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-12-19

D · Potential for more than minimal harm 2023-04-10

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2023-05-01

D · Potential for more than minimal harm 2023-04-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-05-01

F · Potential for more than minimal harm 2022-12-02

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-01-12

F · Potential for more than minimal harm 2022-12-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-01-12

E · Potential for more than minimal harm 2022-12-02

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-01-12

E · Potential for more than minimal harm 2022-12-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-01-12

E · Potential for more than minimal harm 2022-12-02

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-01-12

E · Potential for more than minimal harm 2022-12-02

F756 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-01-12