Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elm Terrace Gardens during CMS and state inspections, most recent first.
Surveyors found that required sprinkler system inspection documentation was incomplete, with only three quarterly reports available and the 2nd quarter annual sprinkler report missing. During observation of the exterior car port, one of six sprinkler heads was obstructed by underside aluminum paneling. The Administrator and Maintenance Director confirmed both the missing documentation and the obstruction.
Surveyors found that oxygen cylinders stored within first- and second-floor nurses' stations were placed less than five feet from electrical receptacles and combustible materials, in violation of NFPA 99/101 requirements for separation of oxidizing gases from combustibles and ignition sources. The Administrator and Maintenance Director confirmed during interview that the cylinders were improperly stored in proximity to these combustible and ignition sources.
The facility failed to maintain and test its generator system as required, affecting the entire facility. Missing documentation included a natural gas reliability letter and records of monthly battery testing. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the fire-resistance rating of stair towers used as exits, affecting one of three levels. This was determined through observation and interview, showing non-compliance with NFPA 101 standards.
The facility was cited for fire safety and sprinkler system maintenance deficiencies. An unsealed penetration around fire alarm wiring was observed above a door in the second-floor stair tower. Additionally, a review of documents showed that required sprinkler gauge replacements, noted in an August 2024 report, had not been addressed by the time of the survey. These issues were confirmed during an exit interview with the facility's administration.
The facility did not maintain the fire resistance rating of its rubbish chutes, as observed when the rubbish chute door on the second floor Skilled Nursing Trash Room failed to self-close and latch. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not conduct a required fire drill for the second shift in the second quarter of 2024, as identified during a document review. This deficiency was confirmed in an interview with the Administrator and Maintenance Director, indicating non-compliance with NFPA 101 standards for quarterly fire drills on each shift.
The facility failed to maintain dignity during meal assistance for three residents with cognitive impairments and feeding difficulties. Observations showed that NAs stood while assisting these residents, contrary to facility protocols. The Administrator confirmed that staff should not stand over residents during feeding.
A facility failed to accurately complete the MDS assessment for a resident, incorrectly documenting a stage two pressure ulcer upon admission. Clinical records and staff interviews revealed no evidence of such a condition, and the DON confirmed the inaccuracy.
The facility failed to maintain sanitary food service practices in one dining area. A dietary aide was observed using the same pair of gloves for multiple tasks, including assisting a resident with utensils, clearing soiled plates, and preparing food for other residents, without changing gloves between tasks. This was contrary to the facility's hand hygiene policy, which requires changing gloves between tasks.
A facility failed to implement care planned interventions for a resident with a history of stroke and cognitive impairment, who was at risk for falls. The care plan required a fall mat to be placed on the left side of the bed, but observations on two days showed the mat was missing. This was confirmed by the Community RN Educator.
Incomplete Sprinkler Inspection Records and Obstructed Exterior Sprinkler Head
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 25 requirements for inspection, testing, and maintenance of the automatic sprinkler system. During document review, only three quarterly sprinkler inspection reports were available for the following time frames: 4th quarter dated 3/10/26, 3rd quarter dated 11/5/25, and 1st quarter dated 5/15/25, and the 2nd quarter annual sprinkler report was not available for review. In addition, during observation of the exterior car port area, one of six sprinkler heads was found to be obstructed by underside aluminum paneling. At the exit interview, the Administrator and Maintenance Director confirmed both the missing sprinkler system documentation and the obstructed exterior sprinkler head. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to maintain complete sprinkler system inspection records and to ensure unobstructed sprinkler head coverage in the exterior car port.
Plan Of Correction
The Maintenance Director has hired a qualified vendor to facilitate quarterly sprinkler tests and will be conducted during the following months: August 2026, November 2026, and February 2027 to ensure compliance. The Maintenance Director has hired a qualified vendor to repair the sprinkler head within the exterior car port which was obstructed by aluminum paneling. Quarterly sprinkler head maintenance and the exterior sprinkler head repair will be monitored by the Maintenance Director and/or designee and presented to the Quality Council monthly to ensure compliance.
Improper Oxygen Cylinder Storage Near Combustibles and Electrical Receptacles
Penalty
Summary
Surveyors identified a deficiency related to improper storage of oxygen cylinders in the facility. During an observation conducted on the first and second floors between 10:30 a.m. and 12:15 p.m., oxygen cylinders were found stored within the nurses' stations. These cylinders were located less than five feet from electrical receptacles and combustible materials, contrary to NFPA 99 and NFPA 101 requirements for separation of oxidizing gases from combustibles and ignition sources. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the oxygen cylinders were stored less than five feet from combustible and ignition sources. The report does not describe any specific residents, clinical conditions, or adverse events, but focuses on the environmental and storage practices for gas equipment within the nurses' stations on two of the three levels surveyed.
Plan Of Correction
Maintenance staff removed the oxygen cylinders from the first and second floor nurses stations. Nursing posted signage no oxygen cylinders are to be stored at the first and second floor nurses station to ensure cylinders are distanced from combustible materials/ignition sources. Maintenance will complete random monthly audits on first and second floor nurses stations to ensure oxygen is not being stored in those areas and present finding to the Quality Council monthly for review to maintain compliance.
Failure to Maintain and Test Generator System
Penalty
Summary
The facility failed to maintain and test its generator system in accordance with the required standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for specific tests over the past twelve months. These missing documents included a natural gas reliability letter and records of monthly testing of battery specific gravity or battery conductance. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. The lack of documentation indicates that the facility did not adhere to the necessary maintenance and testing protocols for its essential electrical systems, as outlined by NFPA standards. This oversight could potentially impact the facility's ability to ensure a reliable power supply in emergency situations.
Plan Of Correction
Maintenance Director has contacted the facility's natural gas company to obtain a copy of the Natural Gas Reliability Letter. Maintenance Director and/or designee initiated monthly testing of battery specific gravity or battery conductance to ensure the generator is properly maintained. Maintenance Director will present the Natural Gas Reliability Letter and monthly testing of the generator battery to Quality Council for review to ensure compliance.
Failure to Maintain Fire-Resistance Rating in Stair Towers
Penalty
Summary
The facility failed to maintain the fire-resistance rating of stair towers, which are used as exits, affecting one of the three levels. This deficiency was identified through observation and interview, indicating non-compliance with the NFPA 101 standards for stairways and smokeproof enclosures.
Plan Of Correction
Maintenance staff sealed the penetration surrounding the red fire alarm wiring, directly above the door, at the second floor stair tower #3, using through penetration fire stop system number C-BJ-3016 with the corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant CP 25WB+. Maintenance staff will conduct monthly audits in the stair towers to assess for unsealed penetrations and repair as needed. Audits will be presented to the Quality Council for review to ensure compliance.
Fire Safety and Sprinkler System Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to fire safety and sprinkler system maintenance. During an observation on April 7, 2025, at 1:00 p.m., surveyors identified an unsealed penetration surrounding red fire alarm wiring above the door in the second-floor stair tower #3. This issue was confirmed during an exit interview with the Administrator and the Maintenance Director later that day. Additionally, a document review revealed that the facility failed to maintain its sprinkler system as required. The Quarterly Sprinkler report from August 2, 2024, indicated that sprinkler gauges needed replacement by the end of 2024. However, there was no evidence of corrective action taken by the time of the survey on April 7, 2025. This lack of documentation was also confirmed during the exit interview with the facility's administration.
Plan Of Correction
Sprinkler gauges will be replaced by a qualified vendor to ensure the sprinkler system is properly maintained. Maintenance and a qualified vendor will assess sprinkler gauges throughout the facility and report findings to the Quality Council to ensure compliance.
Failure to Maintain Fire Resistance of Rubbish Chute
Penalty
Summary
The facility failed to maintain the fire resistance rating of its rubbish chutes and discharge rooms, specifically affecting one of the three levels. During an observation on April 7, 2025, at 1:10 p.m., it was noted that the rubbish chute door on the second floor Skilled Nursing Trash Room did not self-close and latch when tested. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Maintenance staff repaired the rubbish shoot door in the second floor Skilled Nursing trash room to ensure it self-closes and latches when tested. Maintenance staff will audit the rubbish shoot door monthly to ensure proper functioning and report findings to the Quality Council to ensure compliance.
Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct a required fire drill for the second shift during the second quarter of 2024. This deficiency was identified during a document review on April 7, 2025, at 9:00 a.m. The absence of this fire drill was confirmed during an exit interview with the Administrator and the Maintenance Director later that day at 2:00 p.m. The report indicates that the facility did not meet the requirement of holding fire drills at least quarterly on each shift, as mandated by NFPA 101 standards.
Plan Of Correction
Maintenance staff will ensure fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. Maintenance staff will review fire drill logs with the Quality Council to ensure compliance.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents in one of the dining areas. Resident 18, diagnosed with Alzheimer's disease and dysphagia, required total assistance with feeding due to cognitive impairment. Similarly, Resident 27, also diagnosed with Alzheimer's disease and dysphagia, and Resident 54, with frontotemporal neurocognitive disorder, both required total assistance with feeding as per their care plans. However, observations revealed that nurse aides were standing while assisting these residents with their meals, which was against the facility's protocol for feeding residents. The observations took place on March 25, 2025, where NA 1 was seen standing while assisting Residents 18, 27, and 54, and NA 2 was observed standing while assisting Resident 27. In an interview, the Administrator confirmed that staff were instructed not to stand over residents while feeding them, indicating a failure to adhere to the facility's guidelines for maintaining resident dignity during meals.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident. Upon review of the clinical records and staff interviews, it was found that the MDS assessment inaccurately documented the presence of a stage two pressure ulcer upon the resident's admission. The admission nursing assessment did not provide evidence of a pressure ulcer, and a registered nurse confirmed that the resident did not have any pressure ulcers during admission. However, the MDS assessment incorrectly indicated the presence of a stage two pressure ulcer. The Director of Nursing confirmed the inaccuracy of the MDS assessment.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to serve food in a sanitary manner in one of its dining areas, specifically on the Second Floor. The deficiency was identified through a review of the facility's Hand Washing/Hand Hygiene policy, dated January 7, 2025, which requires staff to wash their hands and change disposable gloves between tasks that may soil them. On March 25, 2025, Dietary Aide 1 was observed wearing the same pair of gloves while assisting a resident with utensils, clearing soiled plates, and preparing plates of food for other residents, without changing gloves between these tasks. This observation was confirmed in an interview with the Administrator on March 27, 2025, who stated that staff are expected to change gloves between tasks.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care planned interventions for a resident who was admitted with a history of stroke, resulting in weakness on one side of the body, and altered mental status. The resident was identified as having a risk for falls due to confusion and lack of safety awareness. The care plan specified that a fall mat should be placed on the left side of the bed and checked every shift. However, observations on two consecutive days revealed that the fall mat was not in place while the resident was in bed. This deficiency was confirmed during an interview with the Community Registered Nurse Educator, who acknowledged that the fall mat should have been in place.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lansdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Rehabilitation And Care Center At Lansd | 0.2 mi | ★★★★★ | 19 | 0 |
| St Mary Center For Rehabilitation & Healthcare | 0.7 mi | ★★★★★ | 15 | 0 |
| Montgomeryville Skilled Nursing And Rehabilitati | 1.9 mi | ★★★★★ | 0 | 0 |
| Gwynedd Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Dock Terrace | 3.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.