Inspection Reports for Elm Terrace Gardens
660 N Broad St, Lansdale, PA 19446, PA, 19446
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Inspection Report
Monitoring
Census: 76
Capacity: 250
Deficiencies: 1
Apr 28, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility on 04/28/2025.
Findings
The facility was found to have direct care staff deficiencies related to educational qualifications, with seven staff members lacking a high school diploma, GED, or active registry status. A plan of correction was submitted and fully implemented to address these issues, including termination and conditional re-hire pending GED enrollment.
Deficiencies (1)
| Description |
|---|
| Direct care staff persons A, B, C, D and E do not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
Residents Served: 76
License Capacity: 250
Direct Care Staff without required qualifications: 7
Staffing Hours - Total Daily Staff: 119
Staffing Hours - Waking Staff: 89
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 5
Residents Age 60 or Older: 76
Residents with Mobility Need: 43
Inspection Report
Follow-Up
Census: 81
Capacity: 250
Deficiencies: 4
Feb 10, 2025
Visit Reason
The visit was a partial, unannounced inspection triggered by a complaint and incident review, including follow-up on previously submitted plans of correction.
Findings
The facility was found to have deficiencies related to failure to report suspected resident abuse, inadequate assistance with activities of daily living as per resident support plans, resident abuse resulting in injury and death, and failure to document refusal or inability to sign support plans. Plans of correction were submitted and implemented with ongoing monitoring.
Complaint Details
The inspection was complaint-related and incident-driven, including investigation of alleged abuse and failure to follow reporting requirements. The Department of Human Services investigated and was satisfied with subsequent reporting.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan, specifically supervision and documentation of safety checks. |
| Resident abuse involving leaving a resident unattended leading to a fall resulting in subdural hemorrhage and subsequent death. |
| Failure to document a resident's inability or refusal to sign the support plan. |
Report Facts
License Capacity: 250
Residents Served: 81
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 8
Residents Age 60 or Older: 81
Residents with Mobility Need: 35
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Renewal
Census: 83
Capacity: 250
Deficiencies: 11
Nov 25, 2024
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 11/25/2024, 11/26/2024, and 12/23/2024, to assess compliance with licensing requirements and investigate incidents.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, failure to provide required supervision leading to resident elopement, abuse concerns related to elopement risk, lack of required fire safety training for some staff, incomplete fire drill records, improper medication storage and administration documentation, and incomplete medical evaluations and support plans for residents in the secured dementia care unit. Plans of correction were accepted and implemented by 02/13/2025.
Deficiencies (11)
| Description |
|---|
| Resident records were found unlocked and accessible to visitors and non-medical staff on the 3rd-floor nurses station counter. |
| Resident #1 did not receive required supervision and eloped from the secured dementia care unit (SDCU), staff failed to document safety checks and resident lacked required pendant. |
| Resident #1 eloped from the SDCU using a delayed egress fire stairwell exit; staff did not receive alarm notifications and delayed resident search. |
| Staff persons C and D did not receive required annual fire safety training during the 2023 training year. |
| Fire drill records lacked exact evacuation times in seconds for drills conducted between 03/13/24 and 10/28/24. |
| Fire drills were routinely held during the last week of each month, not on varied days and times as required. |
| Expired medications (Apotex 5mg and Novolog) were found in the medication cart beyond manufacturer expiration or discard dates. |
| Resident #2's prescribed Acetaminophen 325mg as needed was not available in the home on 11/26/24. |
| Resident #4's medication administration record lacked initials of staff administering Oxycodone on multiple dates/times. |
| Resident #1's medical evaluation was not completed within 60 days prior to admission to the SDCU as required. |
| Support plans for residents #1 and #5 did not reflect their inability to safely use or avoid poisonous materials despite residing in the SDCU. |
Report Facts
License Capacity: 250
Residents Served: 83
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Hospice Residents: 7
Resident Mobility Need: 48
Staffing Hours: 131
Waking Staff: 98
Inspection Report
Follow-Up
Census: 81
Capacity: 250
Deficiencies: 4
Oct 16, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The inspection found multiple deficiencies related to treatment of residents, medication storage, positive interventions, and prohibitions on mechanical restraints. The facility implemented corrective actions including staff suspension and termination, in-service training, audits, and ongoing monitoring.
Deficiencies (4)
| Description |
|---|
| A resident was combative and resistant to care; staff used inappropriate physical handling and retaliated by tapping the resident after being punched. |
| Medication blister pack was punctured and taped over, compromising medication storage integrity. |
| Failure to implement positive interventions to modify or eliminate resident's aggressive behavior; staff did not properly redirect the resident. |
| Use of mechanical restraint by staff lowering resident into wheelchair against resident's refusal and without assistance, contrary to resident's care plan. |
Report Facts
License Capacity: 250
Residents Served: 81
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 7
Residents Age 60 or Older: 81
Residents with Mobility Need: 48
Residents with Physical Disability: 2
Staff Total Daily: 129
Staff Waking: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Administrator | Initiated internal investigation and suspended staff member A | |
| Nurse Educator | Conducted in-service training on Abuse and Neglect prevention and detection | |
| Clinical Director | Removed and properly destroyed compromised medication and conducted medication audits | |
| Staff Member A | Involved in multiple violations including improper resident handling and employment terminated |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 250
Deficiencies: 0
Sep 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 09/18/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 250
Residents Served: 80
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 7
Residents Age 60 or Older: 80
Residents with Mobility Need: 46
Residents with Physical Disability: 2
Total Daily Staff: 126
Waking Staff: 95
Inspection Report
Follow-Up
Census: 80
Capacity: 250
Deficiencies: 6
May 29, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident at the facility, specifically a review of a submitted plan of correction related to resident abuse and other regulatory compliance issues.
Findings
The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, physical and verbal abuse of residents by staff, privacy violations due to unposted voice-activated devices, failure to ensure direct care staff completed required training, obstructed emergency egress signage, and failure to update support plans after resident falls. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was triggered by an incident involving suspected resident abuse, including theft and physical/verbal abuse captured on video, which was reported by family and staff. Staff Member B was terminated and reported to authorities. An internal investigation and corrective actions were implemented.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident, specifically a jewelry theft not reported to the local area agency on aging. |
| Physical and verbal abuse of Resident 2 by Staff Member B, including pushing, kicking, and verbal intimidation captured on video. |
| Privacy violation due to presence of a voice-activated electronic device in Resident 1's apartment without posted notice. |
| Direct care staff person provided unsupervised ADL services without completing required Department-approved training and competency test. |
| Obstruction of emergency egress by a STOP sign posted on the front door of the memory care unit. |
| Failure to revise Resident 2's support plan after two falls to reflect changes in condition and care needs. |
Report Facts
License Capacity: 250
Residents Served: 80
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Residents Diagnosed with Mental Illness: 24
Residents Aged 60 or Older: 80
Residents with Mobility Need: 41
Residents with Physical Disability: 3
Inspection Report
Follow-Up
Census: 76
Capacity: 250
Deficiencies: 6
Nov 16, 2023
Visit Reason
The inspection visit on 11/16/2023 was a partial, unannounced follow-up to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report details deficiencies related to resident abuse, mobility assessment, and support plan revisions, all of which have been addressed with updated plans and staff training.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident; delay in reporting to the Department. |
| Resident physically abused by staff resulting in a fall and injury; staff terminated. |
| Resident's mobility needs assessment was incomplete and inconsistent with medical documentation. |
| Support plan was not revised timely to reflect changes in resident's needs after multiple falls. |
| Support plan did not document how moderate mobility needs would be met. |
| Resident did not sign the support plan and no indication of refusal or inability to sign. |
Report Facts
License Capacity: 250
Residents Served: 76
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Resident Mobility Need: 40
Residents 60 Years or Older: 76
Residents Diagnosed with Mental Illness: 2
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Renewal
Census: 79
Capacity: 250
Deficiencies: 24
Sep 21, 2023
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons on 09/21/2023, 09/22/2023, and 10/03/2023.
Findings
The facility was found to have multiple deficiencies including failure to post regulations, improper refund processing after resident deaths, abuse and neglect issues related to a resident fall and COVID-19 exposure, privacy violations, lack of criminal background checks for staff, unsecured poisonous materials, uncovered trash receptacles, ventilation issues, furniture and equipment disrepair, incomplete first aid kits, kitchen sanitation and food safety violations, emergency procedure deficiencies, evacuation drill failures, incomplete medical evaluations, medication storage and prescription issues, incomplete resident records, and support plan documentation errors. Plans of correction were accepted and implemented by mid-November 2023.
Deficiencies (24)
| Description |
|---|
| The home's regulation book was not posted in a conspicuous and public place in the home. |
| Refund checks for deceased residents were not issued within the required timeframe. |
| Resident was neglected and suffered multiple injuries after a fall; COVID-19 protocols were not properly followed. |
| Medication plastic bags containing resident's private information were left visible on the medication cart. |
| Criminal background checks were not completed for two staff members. |
| Poisonous materials were unlocked, unattended, and accessible to residents not assessed as capable of safe use. |
| Full, uncovered, unattended trash can found in the main kitchen. |
| Bathrooms lacked operable windows or ventilation fans; vents were inoperable. |
| Bathroom sink clogged and furniture cabinet drawer missing. |
| First aid kits in facility vehicles lacked required supplies such as thermometer, gloves, antiseptics, goggles, and tweezers. |
| Dementia unit kitchen sink and fridge doors were dirty and filthy with food residue. |
| Six ice cream containers were uncovered in the ice cream freezer. |
| Unlabeled and undated leftover food items found in kitchen and memory care unit. |
| Refrigerator and freezer temperatures exceeded safe limits; no thermometer in ice cream freezer. |
| Outdated bread with expiration dates past was found in freezer. |
| Emergency procedures did not include contact information for each resident’s designated person. |
| Evacuation drills exceeded the maximum safe evacuation time specified by a fire safety expert. |
| Medical evaluations for residents 6 and 7 lacked pertinent emergency medical information and body positioning/movement stimulation details. |
| Medication prescribed for resident 8 was discontinued but remained in the medication cart. |
| Procedures for safe storage, access, security, distribution, and use of medications and medical equipment were not properly implemented. |
| Resident 10's preadmission screening form did not document determination that resident's needs can be met by the home. |
| Resident 10's most recent assessment had errors and typos affecting accuracy of support plan dates. |
| Resident 11's support plan did not document how a no-added diet need would be met and lacked resident signature. |
| Resident 3's and resident 12's records did not include color of hair or color of eyes. |
Report Facts
Residents Served: 79
License Capacity: 250
Memory Care Unit Capacity: 24
Memory Care Unit Residents Served: 27
Hospice Current Residents: 6
Residents Diagnosed with Mental Illness: 35
Residents with Mobility Need: 44
Residents 60 Years or Older: 79
Residents with Physical Disability: 2
Inspection Dates: 3
Total Daily Staff: 123
Waking Staff: 92
Inspection Report
Follow-Up
Census: 74
Capacity: 250
Deficiencies: 3
Jul 11, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to violations involving resident dignity, respect, and privacy, including inappropriate staff behavior with a resident. Additional findings included a support plan signature deficiency which was also corrected. Continued compliance was required.
Deficiencies (3)
| Description |
|---|
| Staff person A recorded a resident with a personal cell phone through a window and posted it on social media, violating resident dignity and respect. |
| Staff person A recorded a resident in a vulnerable situation, violating resident privacy. |
| Resident 2 participated in the development of the support plan but did not date the support plan. |
Report Facts
License Capacity: 250
Residents Served: 74
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 19
Total Daily Staff: 111
Waking Staff: 83
Inspection Report
Complaint Investigation
Census: 75
Capacity: 250
Deficiencies: 2
Jun 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Elm Terrace Gardens.
Findings
The inspection found multiple deficiencies related to medication administration and documentation, including failure to document Foley catheter output and missed or improperly timed medication administrations for Resident #1. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related with a follow-up type of Plan of Correction (POC) submission. The plan of correction was fully implemented as of the inspection date.
Deficiencies (2)
| Description |
|---|
| Failure to document Foley catheter output every shift for urinary output on multiple dates. |
| Failure to administer prescribed medications as ordered, including Nitrofurantoin, Trazodone, Macrobid, and Percocet, and failure to complete prescribed wound care and TED hose application on multiple dates. |
Report Facts
License Capacity: 250
Residents Served: 75
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 2
Residents Diagnosed with Mental Illness: 30
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Total Daily Staff: 114
Waking Staff: 86
Inspection Report
Follow-Up
Census: 79
Capacity: 250
Deficiencies: 3
Feb 16, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/16/2022 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included a delayed resident-home contract completion, incomplete medical evaluation missing special health/dietary needs, and a late incident report submission. Directed plans of correction were in place with completion dates in March 2022.
Deficiencies (3)
| Description |
|---|
| Resident #1 did not have a resident-home contract completed until after admission. |
| Resident #1's medical evaluation did not include special health/dietary needs. |
| The home did not report a witnessed fall incident involving Resident #1 to the department within 24 hours as required. |
Report Facts
License Capacity: 250
Residents Served: 79
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 22
Total Daily Staff: 127
Waking Staff: 95
Residents Diagnosed with Mental Illness: 34
Residents with Mobility Need: 48
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 85
Capacity: 250
Deficiencies: 11
Jun 15, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation to review allegations of resident abuse and compliance with regulatory requirements.
Findings
Multiple violations were found including failure to report suspected resident abuse timely, failure to suspend or supervise staff involved in abuse allegations, incomplete incident reporting, improper handling of poisonous materials, medication administration and documentation errors, failure to report medication refusals, incomplete follow-through on prescriber's orders, and incomplete resident records.
Complaint Details
The visit was complaint-related due to an allegation by resident #1 that staff member A hit them on the head on 6/4/21. The complaint was substantiated by findings of failure to report and respond appropriately to the abuse allegation.
Deficiencies (11)
| Description |
|---|
| Failure to report allegation of abuse to Local Agency on Aging and complete Act 13 form within 48 hours. |
| Failure to immediately suspend or develop a supervision plan for staff involved in alleged abuse. |
| Failure to report abuse incident to the department within 24 hours. |
| Direct care staff did not complete required Department-approved training before providing unsupervised ADL services. |
| Poisonous materials were left unlocked and accessible to residents in the secure dementia care unit. |
| Medication administration was not documented at the time of administration. |
| Refusals of prescribed medications were not reported to the prescriber. |
| Failure to follow prescriber's orders including missed medication doses, unavailable hearing aids, and missed urine collections. |
| Resident admitted to secure dementia care unit without completed cognitive preadmission screening. |
| Support plan did not accurately reflect resident's behavioral needs despite progress notes indicating behavioral issues. |
| Resident record did not include incident report dated 6/7/2020. |
Report Facts
Residents Served: 85
License Capacity: 250
Capacity of Secure Dementia Care Unit: 24
Residents Served in Secure Dementia Care Unit: 23
Current Residents in Hospice: 8
Residents Diagnosed with Mental Illness: 30
Residents with Mobility Need: 54
Residents Age 60 or Older: 85
Staff Total Daily: 139
Waking Staff: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse allegation and failure to suspend or supervise | |
| Staff person B | Named in medication administration documentation violation | |
| Staff person C | Received initial abuse report from resident #1 |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 250
Deficiencies: 0
May 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 86
License Capacity: 250
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 23
Total Daily Staff: 143
Waking Staff: 107
Residents Age 60 or Older: 87
Residents with Mobility Need: 57
Inspection Report
Renewal
Census: 81
Capacity: 250
Deficiencies: 10
May 6, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 05/06/2021 and 05/07/2021 to review compliance with licensing requirements.
Findings
Multiple deficiencies were identified including failure to provide timely assistance with activities of daily living, unsecured poisonous materials accessible to residents, lack of protective guards on heat sources, inadequate lighting at bedside, accumulation of lint in dryer vents, improper medication storage and documentation errors, incomplete resident support plans, missing call bell response times in the home's service description, and missing directions for key-locking devices at secure dementia care unit doors. Plans of correction were accepted or directed with follow-up submissions.
Deficiencies (10)
| Description |
|---|
| Resident did not receive timely assistance with toileting and transferring as required by assessment and support plan. |
| Poisonous materials were unlocked and accessible to residents in memory care units despite residents not being assessed capable of safely using or avoiding poisons. |
| No protective guards were in place to prevent residents from coming in contact with or turning on hot burners in memory care units. |
| Resident did not have access to a source of light that can be turned on/off at bedside. |
| Accumulation of lint in the lint trap of the dryer in the memory care wing. |
| Small round white pill found in medication cart drawer; glucometer readings documented on MAR were often not located on the glucometer; glucometer calibration incorrect; medication administration did not follow prescriber's orders. |
| Home's written description of services and activities did not include call bell response times. |
| Resident's preadmission screening form incomplete with missing sections. |
| Resident's support plan did not document mental health, behavioral health, and cognitive functioning needs or how these needs will be met. |
| Directions for operating key-locking devices were not conspicuously posted near doors to Secure Dementia Care Units. |
Report Facts
License Capacity: 250
Residents Served: 81
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Staffing Hours - Total Daily Staff: 138
Staffing Hours - Waking Staff: 104
Residents Diagnosed with Mental Illness: 38
Residents with Mobility Need: 57
Residents with Physical Disability: 1
Medication Administration Errors: 1
Inspection Report
Complaint Investigation
Census: 69
Capacity: 250
Deficiencies: 6
Feb 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a written complaint regarding resident #1's care and treatment.
Findings
The facility was found to have multiple deficiencies including failure to treat a resident with dignity and respect, failure to provide timely complaint status reports and written decisions, inadequate bedroom furniture for resident needs, insufficient supply of linens and towels, and incomplete medical evaluation documentation.
Complaint Details
A written complaint regarding resident #1's care and treatment was filed on 1/8/21. The home failed to provide a status report within 2 business days and did not provide a written decision within 7 days after the complaint submission. The complaint was investigated and deficiencies were found.
Deficiencies (6)
| Description |
|---|
| Resident #1 was not treated with dignity and respect during showering; staff refused to assist properly and made inappropriate comments. |
| The home did not provide a status report within 2 business days after the submission of a written complaint regarding resident #1's care. |
| The home did not provide a written decision explaining the investigation findings and planned actions within 7 days after the complaint submission. |
| Resident #1 was provided a metal folding chair that did not meet transferring needs; recliner was delayed until 3 days after admission. |
| Insufficient supply of bed linens and towels; only 2 towels available for showering resident #1 and no proper sheets or blankets for hospital bed. |
| Medical evaluation for resident #1 did not document dietary needs and lacked documentation of total physical and oral assistance required for evacuation in emergencies. |
Report Facts
Residents Served: 69
License Capacity: 250
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 17
Residents Age 60 or Older: 64
Residents with Mobility Need: 55
Residents with Physical Disability: 1
Inspection Report
Renewal
Capacity: 250
Deficiencies: 0
Jun 4, 2021
Visit Reason
The document is a renewal application and license issuance for Elm Terrace Gardens Personal Care Home, confirming the facility's authorization to operate and advising that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and notified the facility that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
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