Inspection Reports for Traditions of Lansdale
1800 Walnut St, Lansdale, PA 19446, PA, 19446
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Inspection Report
Follow-Up
Census: 67
Capacity: 150
Deficiencies: 2
Jun 5, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction for the facility following an incident.
Findings
The plan of correction was determined to be fully implemented. Two deficiencies were noted: one related to missed timely annual medical evaluations for residents, and another related to improper storage of medications with punctured blister foil. Corrective actions and ongoing quality assurance measures were implemented and accepted.
Deficiencies (2)
| Description |
|---|
| Resident's most recent annual medical evaluation was not completed timely. |
| Medication cards were observed to have punctured blister foil with medication still present in the spot. |
Report Facts
License Capacity: 150
Residents Served: 67
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 5
Residents Age 60 or Older: 67
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 26
Medications Removed Due to Punctured Foil: 6
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Deficiencies: 7
Sep 20, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation related to resident elopement and staff conduct at the secured dementia care unit.
Findings
The inspection found that a resident eloped due to a faulty locking mechanism on a courtyard door and was verbally abused by a staff member. Additional violations included failure to complete criminal background checks, inadequate staff orientation and training, missing support plan signatures, and malfunctioning electronic locking systems.
Complaint Details
The complaint investigation substantiated that a resident eloped from the secured dementia care unit due to a faulty door lock and was verbally abused by a staff member who was subsequently terminated. An Act 13 and Reportable Incident form were filed with DHS.
Deficiencies (7)
| Description |
|---|
| Resident eloped from secured dementia care unit due to faulty locking mechanism on courtyard door. |
| Resident was verbally abused by Staff Member A. |
| Staff Member A did not have a criminal background check completed prior to employment. |
| Staff person B did not receive required fire safety orientation on first day of work. |
| Staff person B did not complete required 40-hour training on resident rights, emergency medical plan, and mandatory reporting of abuse and neglect. |
| Resident participated in support plan development but did not date the support plan. |
| Courtyard door malfunctioned and did not lock properly, allowing resident elopement. |
Report Facts
Residents served: 79
License capacity: 150
Secured Dementia Care Unit capacity: 21
Secured Dementia Care Unit residents served: 20
Hospice current residents: 4
Residents aged 60 or older: 79
Residents with mental illness: 3
Residents with mobility need: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings for verbal abuse of resident and failure to have criminal background check; employment terminated | |
| Staff person B | Named in findings for failure to receive required fire safety orientation and 40-hour training |
Inspection Report
Follow-Up
Census: 85
Capacity: 150
Deficiencies: 2
May 2, 2024
Visit Reason
The visit was a partial, unannounced inspection triggered by a complaint and incident review at the facility on 05/02/2024.
Findings
The inspection found deficiencies related to medication administration training where a staff member administered medications without completing the required Department-approved medication administration course. The submitted plan of correction was accepted and fully implemented by 06/14/2024.
Complaint Details
The inspection was complaint-related and incident-driven, as indicated by the reason for inspection being 'Complaint, Incident'.
Deficiencies (2)
| Description |
|---|
| Staff person A administered medications without successfully completing the Department-approved medication administration course. |
| The medication administration training record for Staff person A did not include supporting documentation that the course was successfully completed since their hire date. |
Report Facts
License Capacity: 150
Residents Served: 85
Secured Dementia Care Unit Capacity: 71
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 5
Residents Age 60 or Older: 84
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 26
Residents with Physical Disability: 9
Inspection Report
Monitoring
Census: 87
Capacity: 150
Deficiencies: 0
Apr 2, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/02/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 150
Residents Served: 87
Secured Dementia Care Unit Capacity: 71
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 9
Resident Age 60 or Older: 86
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 27
Residents with Physical Disability: 9
Resident Support Staff: 114
Waking Staff: 86
Inspection Report
Renewal
Census: 90
Capacity: 150
Deficiencies: 38
Feb 14, 2024
Visit Reason
The inspection was an unannounced full review conducted for renewal and complaint reasons on 02/14/2024 and 02/15/2024 to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including issues with posting current licenses, criminal background checks for construction workers, staffing hours, training, sanitary conditions, medication administration, emergency preparedness, and resident support plans. Plans of correction were accepted and implemented by April 2024.
Deficiencies (38)
| Description |
|---|
| The home's current violation report and a copy of 55 Pa. Code Chapter 2600 were not posted in a conspicuous and public place. |
| The home could not provide background checks for construction workers who had unsupervised access to residents. |
| Direct care staffing hours were below the required minimum for residents with mobility needs. |
| Insufficient direct care hours provided during waking hours. |
| Residents experienced significant delays in call bell response times. |
| Only one staff person certified in obstructed airway techniques and CPR was present during night hours for 90 residents. |
| Administrator completed only 13.75 hours of required annual training. |
| Staff person did not receive required fire safety and emergency preparedness orientation on first day. |
| Staff person did not complete required orientation training within 40 scheduled hours. |
| Bedside mobility devices were not periodically evaluated and were improperly secured or attached. |
| Unclean litter box with cat feces found in resident's room causing heavy odor. |
| Uncovered trash can found in guest bathroom. |
| Hot water temperature exceeded 120°F in resident bathrooms. |
| First aid kit in memory care area lacked eye coverings and thermometer. |
| Staff persons did not know the location of the first aid kit. |
| First aid kit was not easily accessible to staff persons. |
| Ice and snow were present on exterior walkway posing a hazard. |
| Resident's box spring was covered in manufacturer's plastic. |
| Resident did not have clean sheets on bed during inspection. |
| No thermometer in freezer in memory care area. |
| Outdated and unlabeled food items found in memory care refrigerator. |
| Lint buildup found in dryer lint trap and internal ducts. |
| Administrator did not have emergency preparedness plan for local municipality. |
| Written emergency procedures had not been submitted annually to local emergency management agency. |
| No documentation of notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Fire extinguisher in smoking area lacked current inspection tag. |
| Resident's room smelled of smoke outside designated smoking area. |
| First aid kit in resident transport bus lacked breathing shield and eye protector. |
| Staff persons G, H, and I administered medications without completing required medication administration training. |
| Loose pill found in medication cart drawer. |
| Resident glucometer readings were inaccurately transcribed or missing corresponding PRN medications. |
| Resident medication administration records missing prescribed medications. |
| Medication administration times and staff initials were not properly recorded; narcotic log incomplete. |
| Resident did not receive prescribed insulin units per sliding scale; wound medication not available. |
| Medication administration training records for staff persons G, H, and I were incomplete and unsigned by trainer. |
| Resident support plans did not document use, need, risks, or proper use of bedside mobility devices. |
| Resident did not sign support plan despite participation in its development. |
| Resident record missing hospital emergency room records; progress notes indicate paperwork was left at front desk. |
Report Facts
Residents served: 90
License capacity: 150
Resident support staff: 69
Total daily staff: 187
Waking staff: 140
Residents with mobility needs: 28
Direct care hours required: 118
Direct care hours provided: 101
Direct care hours required during waking hours: 89
Direct care hours provided during waking hours: 83
Staff certified in CPR: 1
Hot water temperature: 122.3
Inspection Report
Complaint Investigation
Census: 90
Capacity: 150
Deficiencies: 6
Jan 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 01/03/2024.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, unsanitary kitchen conditions, unlabeled soap bars in the memory care unit, improper medication dispensing practices, and medication administration errors. The facility submitted a plan of correction which was accepted and later fully implemented.
Complaint Details
The inspection was complaint-driven, triggered by allegations including medication errors, resident falls, and inappropriate staff-resident interactions. The complaint was substantiated by findings of multiple violations.
Deficiencies (6)
| Description |
|---|
| Failure to report medication error, resident fall, and inappropriate staff-resident interaction incidents to the department within 24 hours. |
| Kitchen floor under equipment was strewn with dried food debris and dust balls; floors between countertops were wet and stained; inner surface of walk-in freezer door was soiled with an unknown black substance. |
| Unlabeled used bars of soap found in shower stalls and bathroom sink in the memory care unit spa. |
| Medications for residents going out for less than two weeks were given to family members in small envelopes rather than original labeled containers. |
| Resident was not administered prescribed medication at bedtime for a period, but staff documented administration by initials. |
| Resident was not administered prescribed medication at bedtime due to medication unavailability in the home. |
Report Facts
License Capacity: 150
Residents Served: 90
Residents in Secured Dementia Care Unit: 18
Total Daily Staff: 118
Waking Staff: 89
Residents Diagnosed with Mental Illness: 6
Residents with Mobility Need: 28
Residents with Physical Disability: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Quality Services | Conducted training on regulatory requirements and reporting process related to incident reporting. | |
| Food Services Director | Led cleaning and sanitizing of kitchen and conducted training on cleaning standards. | |
| Memory Care Director | Conducted inventories and training on labeling of resident hygiene products and soap. | |
| LPN | Assisted Memory Care Director with training on hygiene product labeling. | |
| Regional Director of Operations | Communicated proper medication dispensing practices and conducted training reviews. | |
| Executive Director | Reviewed incidents, conducted audits, and participated in training related to medication administration and incident reporting. | |
| Community Wellness Nurse | Participated in training and audits related to medication administration. | |
| Clinical Care Coordinator | Notified physician and pharmacy immediately upon discovery of medication unavailability. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 150
Deficiencies: 6
Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Traditions of Lansdale.
Findings
Multiple deficiencies were identified including lack of handicap accessible accommodations for a resident, improper handling and destruction of discontinued medications, missing medications, incomplete preadmission screening forms, and illegible narcotic count records. Corrective actions and training plans were implemented and accepted.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced nature of the visit.
Deficiencies (6)
| Description |
|---|
| Resident 1 does not have handicap accessible accommodations for their wheelchair in their bathroom. |
| Discontinued medications belonging to resident 2 remained in the home, not destroyed according to regulations. |
| Resident 1's prescribed medication was not available in the home on the inspection date. |
| Staff Person A did not follow procedure requiring two staff members present during destruction of narcotics; 4 syringes belonging to resident 2 were missing and undocumented. |
| Resident 3's preadmission screening form was completed after admission, not within 30 days prior as required. |
| Resident 2's narcotic count sheet had multiple lines of scribbled out names making it illegible. |
Report Facts
Licensed Capacity: 150
Residents Served: 87
Secured Dementia Care Unit Capacity: 71
Secured Dementia Care Unit Residents Served: 20
Resident Mobility Need Count: 28
Residents Age 60 or Older: 87
Total Daily Staff: 115
Waking Staff: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Assistant Executive Director | Named in findings related to failure to follow narcotic destruction procedures and medication management oversight |
Inspection Report
Census: 81
Capacity: 150
Deficiencies: 0
Jun 1, 2022
Visit Reason
The inspection was conducted as a partial licensing inspection due to an incident at the facility on 06/01/2022.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Resident Support Staff: 81
Waking Staff: 61
License Capacity: 150
Residents Served: 81
Secured Dementia Care Unit Capacity: 77
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlotte Wiley | Lead Inspector | Department representative conducting the inspection |
Inspection Report
Renewal
Census: 67
Capacity: 150
Deficiencies: 15
Sep 28, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Traditions of Lansdale facility on 09/28/2021 and 09/29/2021.
Findings
The inspection identified multiple deficiencies including inadequate First Aid/CPR trained staff during night hours, unsecured poisonous materials accessible to residents, sanitary condition issues, incomplete first aid kits, outdated food items, incomplete medical evaluations, medication management errors, missing medication storage and administration procedures, incomplete medication records, and delayed admission support plans. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (15)
| Description |
|---|
| Only one staff person certified in First Aid/CPR was present during night hours for 67 residents. |
| The activity closet in the Secured Dementia Care Unit was unlocked with poisonous cleaning supplies accessible to residents. |
| Sanitary conditions issues included unlabeled shower puffs and feces stains in resident room #13 bathroom and hallway. |
| First aid kits lacked breathing shield, eye covering, scissors, adhesive tape, and had non-working thermometers. |
| Unlabeled and undated food items found in the SDCU kitchen cupboard. |
| Resident #1's medical evaluation did not include body positioning/movement information. |
| Discontinued medication and equipment were found in the medication cart for residents #2 and #3. |
| Medication prescribed to resident #2 was not available in the home on 09/29/2021. |
| Medication count discrepancies for residents #5 and #6 due to staff not logging sign-out sheets. |
| Resident #2's medication administration record did not indicate diagnosis/purpose for medication. |
| Medication administration records lacked staff initials for multiple medication administrations for residents #1, #2, and #7. |
| Repeated violation: Resident #2 was administered medication beyond prescribed dates; Resident #4 missed blood sugar checks on multiple dates. |
| Staff person A lacked documentation of annual medication administration practicum for 2020 but administered medications in 2021. |
| Resident #8's initial support plan was not completed within 72 hours of admission to the Secured Dementia Care Unit. |
| Controlled substance sign-out sheet for resident #2 had a crossed-out entry. |
Report Facts
Residents present during night hours: 67
Cleaning supply bottles accessible: 3
License capacity: 150
Residents served: 67
Memory care capacity: 71
Memory care residents served: 17
Hospice residents: 2
Staff total daily: 93
Waking staff: 70
Inspection Report
Plan of Correction
Census: 66
Capacity: 150
Deficiencies: 1
Sep 13, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted on 09/13/2021 due to an incident at the facility.
Findings
The report details an abuse incident where one resident was found lying on the floor after being pushed and hitting their head by another resident. The injured resident was later diagnosed with a left pelvic fracture. The facility submitted a plan of correction which was determined to be fully implemented.
Deficiencies (1)
| Description |
|---|
| A resident was neglected and physically abused resulting in a left pelvic fracture. |
Report Facts
License Capacity: 150
Residents Served: 66
Residents Served in Secured Dementia Care Unit: 16
Capacity of Secured Dementia Care Unit: 38
Total Daily Staff: 91
Waking Staff: 68
Inspection Report
Follow-Up
Census: 59
Capacity: 150
Deficiencies: 2
Sep 8, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 09/08/2021 to review the submitted plan of correction related to a prior incident.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were noted: one involving a staff member hired without a completed criminal background check prior to their first day of work, and another regarding direct care staff not having access to or training on resident support plans.
Deficiencies (2)
| Description |
|---|
| Staff person hired did not have a criminal history background check completed prior to their first day of work. |
| Direct care staff have not been trained to access and review resident support plans, and a paper copy is not kept in an accessible location. |
Report Facts
License Capacity: 150
Residents Served: 59
Memory Care Capacity: 38
Memory Care Residents Served: 15
Total Daily Staff: 83
Waking Staff: 62
Residents with Mobility Need: 24
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Residents 60 Years or Older: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation. | |
| Michele Swisher | Lead Inspector | On-site inspector for the 09/08/2021 visit. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 150
Deficiencies: 2
Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint regarding the discharge of a resident against their wishes.
Findings
The facility was found to have improperly discharged a resident against their wishes without meeting the permitted conditions for discharge. Additionally, a resident admitted to the secured dementia care unit did not have a support plan completed within the required 72 hours.
Complaint Details
The complaint investigation found that resident #1 was discharged against their wishes after hospital evaluation, with the facility refusing to accept the resident back despite no medical need for admission. The discharge was not for any permitted condition under regulations.
Deficiencies (2)
| Description |
|---|
| Discharged resident #1 against the resident's wishes without meeting permitted conditions for discharge. |
| Resident #2 admitted to the Secure Dementia Care Unit did not have an initial support plan completed within 72 hours of admission. |
Report Facts
License Capacity: 150
Residents Served: 57
Memory Care Unit Capacity: 38
Memory Care Unit Residents Served: 13
Current Hospice Residents: 1
Residents with Mobility Need: 24
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 56
Capacity: 150
Deficiencies: 5
Feb 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation due to a complaint related to resident care and call bell system malfunction.
Findings
The inspection found multiple deficiencies including failure to assist a resident with oxygen and bathroom needs due to a malfunctioning call bell system, employment of a direct care staff member without required qualifications, tripping hazards from floor repairs, missing flood light with exposed electrical wires, and systemic issues with the call bell system requiring replacement.
Complaint Details
The visit was complaint-related due to a resident's call bell request not being answered because of a malfunctioning call bell system. The complaint was substantiated as neglect related to failure to assist the resident.
Deficiencies (5)
| Description |
|---|
| Resident #1 did not receive required assistance with oxygen and was forced to sleep in a recliner due to call bell system malfunction. |
| Resident #1 was neglected when staff failed to respond to call bell requests due to systemic call bell malfunction. |
| Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Several cement patches and unsecured carpet pieces in the memory care unit presented tripping hazards. |
| A flood light was missing outside a room in the memory care unit, leaving two exposed electrical wires, one capped and one uncapped. |
Report Facts
Residents served: 56
License capacity: 150
Memory care unit capacity: 71
Memory care residents served: 18
Current hospice residents: 2
Residents age 60 or older: 56
Residents with mobility need: 33
Total daily staff: 89
Waking staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Direct Care Staff | Found to lack required qualifications and no longer employed |
| Executive Director | Confirmed replacement of call bell system and coordinated corrective actions | |
| Maintenance Director | Responsible for flood light repair and floor hazard corrections | |
| Business Office Manager | Received training on employee records and employment requirements | |
| Resident Care Director | Coordinates daily review of call bell system reports with Executive Director |
Notice
Capacity: 150
Deficiencies: 0
Jan 25, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Traditions of Lansdale' following the receipt of a renewal application. It also informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum licensed capacity: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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