Federal inspection record · CMS data as of October 1, 2026
Garden Spring Rehab And Care Center
1113 North Easton Road, Willow Grove, PA · (215) 830-5400
- Certified beds
- 173
- Residents per day
- 137
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 1, 1967
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Pennsylvania.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Pennsylvania homes
Garden Spring Rehab And Care Center carries 109 inspection points. That is fewer than 25% of Pennsylvania's 652 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Pennsylvania: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–8 pts
- 4★ 8–33 pts
- 3★ 33–65 pts
- 2★ 65–128 pts
- 1★ over 128 pts
Bars show every rated home in Pennsylvania by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
46 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
K
Provide and implement an infection prevention and control program.
Everything else, by area of care
Quality of Life and Care19D
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Resident Rights10E
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- E
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.
- E
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.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Assessment and Care Planning5E
- E
Ensure each resident receives an accurate assessment.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Assess the resident when there is a significant change in condition
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pharmacy Service3E
- D
Ensure medication error rates are not 5 percent or greater.
- D
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.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Infection Control2F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration1C
- C
Hire a qualified full-time social worker in a facility with more than 120 beds.
Inspection history
2024-10-18
7 health deficiencies · 0 fire-safety deficiencies
Top issue: Resident Rights (4 deficiencies)
2023-11-16
12 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2022-12-02
27 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 33 min of nursing staff time a day, 26 min of it from a registered nurse.
This home
3 h 33 min
Pennsylvania average
3 h 54 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 64% of nursing staff and 53% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$15,753 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-11-05 | Fine | $15,753 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.7 pts worse | 3.2 | 1.5 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.1 pts better | 1.0 | 1.1 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine24.3 pts worse | 63.5% | 87.8% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.7 pts worse | 91.0% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts better | 2.0% | 3.1% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.3 pts better | 9.5% | 13.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.9 pts worse | 10.9% | 6.0% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.5 pts better | 19.6% | 20.1% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3 pts worse | 20.6% | 17.6% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.2 pts better | 0.0% | 0.2% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.6 pts better | 9.8% | 15.4% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.7 pts better | 8.7% | 16.4% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.6% | 0.6% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts better | 0.8% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.8 pts worse | 25.8% | 25.0% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.1 pts better | 4.6% | 4.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine55.4 pts worse | 15.4% | 70.8% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.7 pts better | 8.8% | 9.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.7 pts worse | 2.1% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine59.1 pts worse | 11.8% | 70.9% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.3 pts worse | 26.3% | 22.0% | 23.4% |
·
Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness7C
- C
Address subsistence needs for staff and patients.
- C
Address patient/client population and determine types of services needed.
- B
Establish policies and procedures for sheltering.
- B
Establish roles under a Waiver declared by secretary.
- B
Develop and maintain an Emergency Preparedness Program (EP).
- B
Conduct risk assessment and an All-Hazards approach.
- B
Address patient/client population and determine types of services needed.
·
Other homes nearby
-
Willow Grove Post Acute
Hatboro, PA · Marquis Health Services
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 33 min
- Fines
- $0
-
Brookside Healthcare & Rehabilitation Center
Roslyn, PA · Nationwide Healthcare Services
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 32 min
- Fines
- $0
-
Luther Woods Nursing And Rehabilitation Center
Hatboro, PA · Lifeworks Rehab
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 53 min
- Fines
- $0