Inspection·December 30, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and review of clinical record, it was determined that the facility failed to ensure timely and accurate medication administration for two of five residents reviewed (Resident R1, and Resident R6)Review of facility policy 'Administering medications,' revised April 2019, indicates that medications are to be administered in a safe and timely manner as prescribed. Further review of policy indicates that medications are administered in accordance with prescriber orders, including any required time frames. Review of Resident R1's electronic medication administration report (e-MAR), dated September 21, 2025, revealed an order for Carbidopa Levodopa, extended release 70-280 milligrams (mg), scheduled to be administered at 9:00 am for Parkinson's disease (progressive disease of the central nervous system). Further review of the e-MAR revealed that the medication was not administered until 3:49 pm. Continued review of the e-MAR revealed the medication Keppra, 500 mg, was scheduled to be administered at 9:00 am for seizure disorder, but was not administered until 6:59 pm. Further review of audit e-MAR indicated that Escitalopram, 20 mg, was scheduled to be given at 9:00 am. Further review of the e-MAR revealed that the medication was not administered until 3:48 pm. Continued review of the e-MAR, indicated Medline active liquid protein, 30 mls, was scheduled to be given at 8:00 am. Further review of the e-MAR revealed that the medication was not administered until 3:46 pm. Review of Resident R6's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Congestive Heart Failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, causing fluid to back up (congest) in the lungs, legs, and other areas, leading to symptoms like shortness of breath, fatigue, and swelling), Hypertension (high blood pressure), Depression (sadness and loss on interest), Atrial Fibrillation (type of irregular heartbeat (arrhythmia), where the heart's upper chambers quiver chaotically) Observation and interview held with Resident R6 on December 31, 2025 at 10:13 a.m. Resident R6 had not received their medications at the time of interview on December 31, 2025. Review of facility medication administration times revealed medication are administered at 8AM or 9AM with an hour window given before or after. Observation on December 30. 2025 of the second-floor nursing unit revealed licensed nurse Employee E3 was observed at 10:21 a.m. at the medication cart crushing medications. Once the surveyor passed Resident R5's room, Employee E3 was observed leaving the medication cart and going into Resident R5's room empty handed and walking out with a medication cup in hand containing several pills. When asked the licensed nurse Employee E3 stated that she went to crush Resident R5's roommate (Resident 4's) medication while she was waiting for Resident R5 to take her medication. The medication cart was located two rooms down from Resident R5's room on the opposite side of the hallway. When asked if this was standard practice to leave medications beside with a resident, the nurse stated that it was not. When asked how many residents the licensed nurse had today Employee E3 counted the census sheet and was assigned 31 residents for day shift and stated at the time she was still completing morning Residents Affected - Few (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 3 Event ID: 396017 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 396017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Grove Post Acute 3485 Davisville Road Hatboro, PA 19040 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)