Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable
environment was maintained on three of four nursing units. (Units 1, 2, 3)
Findings include:
On November 13, 2023, at 11:24 a.m., standing water was observed on the floor in the hallway outside of
room [ROOM NUMBER] and the shower room opposite room [ROOM NUMBER]. In an interview at this
time with Housekeeper 1, it was revealed that this had been an ongoing problem for longer than two weeks.
On November 15, 2023, at 11:40 a.m., the shower room opposite room [ROOM NUMBER] was cluttered
with numerous shower beds and equipment, the toilet seat on the toilet was crooked, protruding into a
walking path. There were black spots on the floor and the sink. The sharps container on the wall was filled
beyond capacity. Multiple bottles of soap/shampoo were sitting on top of the sharps container and blocking
the grab rails of the shower stall sides. There was a rust stain on the shower stall floor.
On November 13, 2023, at 11:02 a.m., there was a hole in the wall behind the door in room [ROOM
NUMBER], molding was missing from around the air conditioning unit, and a black piece of foam was
dangling in the space between the wall and the air conditioner. The threshold in the doorway between the
bedroom floor and the bathroom floor was missing, creating an uneven floor surface.
On November 13, 2023, at 9:53 a.m. and on November 16, 2023, at 11:46 a.m., the cover to the air
conditioning unit in room [ROOM NUMBER] was missing.
On November 13, 2023, at 12:00 p.m., the cover to the air conditioning unit in room [ROOM NUMBER] was
missing. On November 14, 2023, at 1:10 p.m., the toilet bowl in room [ROOM NUMBER] had a dark ring
around it. The bathroom door was marred and scratched.
On November 13, and November 14, 2023, at various times, there was a broken closet door and a broken
lower dresser drawer in room [ROOM NUMBER]. In room [ROOM NUMBER], the closet door was off the
track, the privacy curtain was soiled with brown stains, and there was a hole on the bathroom door.
CFR 483.10(i) Safe Environment
Previously cited 12/2/22
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
395077
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
28 Pa. Code 201.18(b)(3) Management.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, observations, and staff interview, it was determined that the facility failed to
ensure physician's orders were implemented for one of 27 sampled residents. (Resident 118)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 118 had diagnoses that included osteoarthritis of both knees
and hips, high blood pressure, and stroke. A physician's order dated June 14, 2023, directed staff to apply
heel boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan
revealed that the resident was at risk for skin breakdown. Multiple observations on November 13 through
15, 2023, between 9:46 a.m. and 1:30 p.m., revealed Resident 118 in bed and the heel boots were not
applied.
In an interview on November 16, 2023, at 9:48 a.m., the Director of Nursing confirmed that staff did not
apply the heel boots as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, facility policy review, and staff interview, it was determined that the facility failed to
provide restorative nursing services to increase or prevent a reduction in range of motion for three of 27
sampled residents. (Residents 36, 47, 116)
Findings include:
Review of the facility policy entitled, Restorative Nursing Services, reviewed October 30, 2023, revealed
that restorative nursing programs were to be individualized to specific resident needs and the care plan was
to be updated or developed to include interventions to support the resident's restorative nursing program.
Clinical record review revealed that Resident 36 had diagnoses that included quadriplegia and neuropathy.
Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 36 had
functional limitation in range of motion to his upper and lower limbs. On November 10, 2023, the
occupational therapist recommended a restorative nursing program for passive range of motion to upper
and lower limbs for 15 minutes daily. There was no documented evidence that the facility provided the
recommended restorative nursing program.
Clinical record review revealed that Resident 47 had diagnoses that included a history of a stroke with left
sided weakness. Review of the MDS assessment dated [DATE], revealed that Resident 47 had functional
limitation in range of motion to his upper and lower limbs. Review of the care plan revealed that staff was to
provide restorative nursing program for passive range of motion to upper and lower limbs for 15 minutes
daily. There was no documented evidence the facility provided the recommended restorative nursing
program for 20 days between October 18 and November 16, 2023.
Clinical record review revealed that Resident 116 had diagnoses that included left sided paralysis,
neuropathy, and muscle weakness. Review of the MDS assessment dated [DATE], revealed that Resident
116 had functional limitation in range of motion to his upper and lower limbs. On September 28, 2023, the
occupational therapist recommended a restorative nursing program for passive range of motion to upper
and lower limbs. There was no documented evidence that the facility provided the recommended restorative
nursing program.
In an interview on November 16, 2023, at 9:55 a.m., the Director of Nursing confirmed the recommended
restorative nursing programs were not implemented for these residents.
CFR 483.25(c) Mobility
Previously cited 12/2/2022
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, policy review, observation, and resident and staff interview, it was determined that the
facility failed to ensure that staff properly secured smoking materials for one of one sampled resident that
smoked (Resident 48) and failed to ensure that safety interventions were in place to prevent accidents for
one of 37 sampled residents. (Resident 88)
Findings include:
Review of the facility's policy entitled, Smoking Policy, last reviewed October 30, 2023, revealed that facility
staff was to keep cigarettes, electronic cigarettes, and lighters in a secure place. In an interview conducted
on Novemeber 16, 2023, at 9:55 a.m., the Director of Nursing stated that staff was to store smoking
materials in a locked cart.
On November 15, 2023, at 10:36 a.m., an electronic cigarette device was observed in Resident 48's room,
not properly secured and accessible to unauthorized residents. In an interview at that time, Resident 48
stated, I keep my electronic cigarette on me.
Clinical record review revealed that Resident 88 had diagnoses that included dementia, muscle weakness,
and lack of coordination. Review of the Minimum Data Set assessment dated [DATE], revealed that the
resident was cognitively impaired and required extensive assistance from staff with mobility. Review of the
care plan revealed that the resident had a history of falls with injury and staff was to place mats at the
bedside. On November 13, 2023, at 11:02 a.m., on November 14, 2023, at 11:22 a.m., on November 15,
2023, at 11:46 a.m., and on November 16, 2023, at 11:50 a.m., Resident 88 was observed in her bed
without fall mats. In an interview on November 16, 2023, at 1:03 p.m., Employee 1 confirmed that fall mats
were not present in the resident's room.
CFR 483.25(d) Accidents
Previously cited 12/2/22
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, resident interview, and staff interview, it was determined that the facility
failed to develop and implement an individualized person-centered plan to render trauma-informed care to a
resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 27 sampled residents.
(Resident 36)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 36 had diagnoses that included PTSD, insomnia, anxiety, and
bipolar disorder. On October 3, 2023, a psychologist noted that the resident had a diagnosis of PTSD and
reported childhood abuse. In an interview on November 13, 2023, at 10:46 a.m., the resident stated he still
thinks about his traumatic childhood and it continues to affect him daily. There was no documented
assessment or care plan that identified symptoms or triggers related to the PTSD diagnosis and there were
no resident specific interventions to meet the resident's needs for minimizing triggers and/or
re-traumatization.
In an interview on November 16, 2023, at 9:48 a.m., the Director of Nursing confirmed that there was no
assessment or care plan developed to address Resident 36's PTSD symptoms or triggers.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395077
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Garden Spring Rehab and Care Center
1113 North Easton Road
Willow Grove, PA 19090
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on review of facility policy and observation, it was determined that the facility failed to ensure that
medications/biologicals were securely stored on one of four nursing units. (Unit 1)
Findings include:
Review of the facility policy entitled, Storage of Medications, last reviewed October 20, 2023, revealed that
drugs and biologicals used in the facility were to be stored in locked compartments and only persons
authorized to prepare and administer medications have access to locked medications. Medication storage
rooms were to be locked when not in use and unlocked medications are not to be left unattended.
On November 15, 2023, at 11:39 a.m., the medication room on Unit 1 was unlocked and unattended. The
refrigerator inside was also unlocked and contained medication including insulin.
On November 16, 2023, from 11:45 a.m. through 11:55 a.m., the medication room on Unit 1 was again
unlocked. There were two open cardboard boxes containing medications, including ibuprofen, in the room.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 7 of 7
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F761 - Labeling of Drugs and Biologicals
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.
- 0007GeneralS&S Cno actual harm
Address patient/client population and determine types of services needed.
- 0015GeneralS&S Cno actual harm
Address subsistence needs for staff and patients.
F584 - Safe Environment
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.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of GARDEN SPRING REHAB AND CARE CENTER?
This was a inspection survey of GARDEN SPRING REHAB AND CARE CENTER on November 16, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDEN SPRING REHAB AND CARE CENTER on November 16, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.