F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, personnel file review, and staff interview, it was determined that the facility
failed to verify professional license and complete a criminal background check prior to the start of
employment for one of five newly hired employees. (E5)
Residents Affected - Few
Findings include:
A review of the facility policy entitled, Background Screening Investigations, dated October 23, 2023,
revealed that the facility was to conduct screening for all potential hires. This included license/registration
verification and a criminal background check.
Employee 5 (E5) had been working in the facility as a Registered Nurse since August 16, 2024, and an
inquiry to the state licensure board and a criminal background check were not completed until October 16,
2024.
In an interview on October 18, 2024, at 9:45 a.m., the Administrator confirmed there was no documented
evidence that the license verification and criminal background check were done prior to start of employment
per facility policy.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.19(3) Personnel policies and procedures.
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 3
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
10/18/2024
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 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on clinical record review and staff interview, it was determined that the facility failed to notify the
resident and the resident's representative(s) of transfer(s), including the reasons for the moves and
Ombudsman information, in writing upon transfer from the facility for five of five sampled residents who
were transferred to the hospital. (Residents 41, 48, 50, 81, 117)
Findings include:
Clinical record review revealed that Resident 41 was transferred to the hospital on August 2 and 16, 2024,
after changes in condition. There was no documentation to support that the resident or the resident's
responsible party or legal representative was provided written information regarding the transfers to the
hospital.
Clinical record review revealed that Resident 48 was transferred to the hospital on June 25, 2024, after a
change in condition. There was no documentation to support that the resident or the resident's responsible
party or legal representative was provided written information regarding the transfer to the hospital.
Clinical record review revealed that Resident 50 was transferred to the hospital on October 5, 2024, after a
change in condition. There was no documentation to support that the resident or the resident's responsible
party or legal representative was provided written information regarding the transfer to the hospital.
Clinical record review revealed that Resident 81 was transferred to the hospital on September 15, 2024,
after a change in condition. There was no documentation to support that the resident or the resident's
responsible party or legal representative was provided written information regarding the transfer to the
hospital.
Clinical record review revealed that Resident 117 was transferred to the hospital on February 21, February
26, April 1, and May 24, 2024, after changes in condition. There was no documentation to support that the
resident or the resident's responsible party or legal representative was provided written information
regarding the transfers to the hospital.
In an interview on October 18, 2024, at 9:51 a.m., the Administrator confirmed that the residents or resident
representatives were not given written notices regarding their transfers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395077
If continuation sheet
Page 2 of 3
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
10/18/2024
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 and staff interview, it was determined that the facility failed to ensure
physician's orders were implemented for one of 26 sampled residents. (Resident 65)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 65 had diagnoses that included hypotension (low blood
pressure). A physician's order dated February 9, 2022, directed staff to administer a medication (midodrine)
three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood
pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its
highest) was greater than 120 millimeters of mercury (mm Hg). Review of Resident 65's medication
administration records revealed that staff administered the medication 17 times in September and six times
in October 2024, when the resident's SBP was greater than 120 mm Hg.
In an interview on October 18, 2024, at 9:39 a.m., the Director of Nursing confirmed that the medications
were administered outside established parameters for Resident 65.
CFR 483.25 Quality of Care
Previously cited 11/16/23
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 3
