Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Gwynedd Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a history of fractures was transported to an outside appointment without wheelchair leg rests. Staff and transport personnel could not locate the footrests, and the resident fell face forward while being wheeled from the van, sustaining a right femur fracture. The facility’s investigation found the wheelchair was used without leg rests, despite the resident’s care plan noting leg rests for transport.
Failure to Update Fall Care Plan After Resident Fall: A resident with dementia, muscle weakness, gait difficulty, spinal stenosis, and a history of falls was found on the floor after walking to the bathroom and falling. The post-fall investigation noted non-skid socks were not in place and the resident was wearing house slippers; the resident was later admitted to the hospital with a hip fracture. The record showed the fall-related care plan had not been reviewed or revised with new interventions to address the root cause of the fall, despite the resident’s ongoing need for supervision with transfers and ambulation.
A resident with dementia, psychotic symptoms, and behavioral disturbances was documented as cognitively impaired, non-English speaking, and communicating through a translator. The care plan called for a calm, step-by-step approach and for staff to stop care if the resident became combative, but during personal care the resident was agitated, swung arms, struck an NA multiple times, and threw a washrag, and the NHA confirmed the planned interventions were not implemented.
A resident with a history of stroke and mobility impairment sustained a laceration during care when they fell while being assisted by a nursing aide. The facility's investigation was incomplete, lacking details such as the duration the resident was standing, the wheelchair's location, and interviews with roommates. Conflicting staff statements about the resident's care needs were noted, and the facility's policies on incident reporting and investigation were not fully adhered to.
A facility failed to update a resident's care plan to reflect their preference for bedside toileting, despite the resident's cognitive intactness and right to choose. The resident, with conditions including cerebral infarction and hemiplegia, sustained an injury during toileting care. Staff confirmed the care plan lacked updates for the resident's preferences and safe instructions, violating the facility's policy for comprehensive, person-centered care plans.
The facility failed to store food according to professional standards, as several bags of hamburger and hotdog buns were not labeled with delivery or best by dates. One bag of hamburger buns showed signs of spoilage with grayish green powdery matter. The Director of Dietary confirmed these observations and discarded the affected items.
A resident was not permitted to return to the facility after hospitalization, despite available beds and policies allowing readmission. The resident, who had dementia and tested positive for COVID-19 without symptoms, was not communicated with regarding readmission plans. Interviews confirmed the lack of documentation and communication with the responsible party.
Wheelchair Leg Rests Not Provided During Transport
Penalty
Summary
The facility failed to ensure Resident R109 was provided with wheelchair leg rests during transportation to an outside appointment. The resident was alert and oriented and had diagnoses including pulmonary hypertension, respiratory failure with hypercapnia, COPD, atherosclerosis, heart failure, morbid obesity, chronic pain, depression, and a history of multiple fractures. Although the resident’s assessment showed no impairments of the upper or lower extremities and that the resident could self-propel a manual wheelchair, the care plan included leg rests in a bag on the back of the wheelchair because of a history of falls and poor safety awareness. On the day of the incident, the resident left the facility for the appointment using facility-arranged transport. Facility and witness statements indicated the wheelchair was used without leg rests, and the transport staff asked where the footrests were before proceeding. The resident was wheeled from the van toward the appointment location when the resident put the feet down and fell face forward onto the pavement. The incident report stated 911 was called and the resident was transported to the hospital with a right femur fracture. Interviews with the resident, nursing staff, transport staff, and the NHA showed the leg rests were not on the wheelchair at the time of transport and staff did not know where they were located. The NHA stated the facility kept leg rests in a bag because they were often misplaced and acknowledged that staff were expected to ensure residents had proper equipment before leaving the facility. The facility’s investigation concluded the wheelchair was used without leg rests and that the resident fell after putting the legs down while being transported.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise Resident R3’s care plan with new interventions after a fall. Resident R3’s annual MDS dated June 27, 2025, documented severe cognitive impairment, dementia, muscle weakness, difficulty walking, an unspecified fall, and spinal stenosis. The assessment also showed the resident required supervision or touching assistance for sit-to-stand transfers and for walking at least 10 feet. The resident’s care plan, dated August 10, 2023, identified decreased ability to perform ADLs, need for toileting assistance, and fall risk related to decreased mobility, history of falls, and poor safety awareness. The most recent intervention added to the fall-related care plan focus was lab work as ordered on February 3, 2025. On September 19, 2025, the resident was found on the floor in front of the bathroom door, lying on the sacrum and left side, with the wheelchair by the bed on the opposite side of the room. The resident reported walking to the bathroom and falling. The post-fall investigation stated the resident took self to the bathroom and fell, that non-skid socks were not in place, and that the resident was wearing house slippers. The resident was transferred to the hospital and admitted with a hip fracture. A statement from an RN indicated the resident was non-compliant with the call bell and used house slippers at the side of the bed to self-transport to the bathroom. The clinical record and care plan contained no documented evidence that the facility reviewed and revised the care plan with new interventions to address the root cause of the fall.
Failure to Implement Care Plan for Combative Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with unspecified dementia with behavioral disturbances, major depressive disorder with psychotic symptoms, and delusional disorder received appropriate treatment and services to attain or maintain the resident’s highest practicable mental and psychosocial well-being. The resident was assessed as cognitively impaired, did not speak English, and communicated through a translator. The care plan identified that the resident was resistant to care and combative, with behaviors including swinging arms and throwing objects, and directed staff to use a calm, slow approach, explain care step by step, and stop the task or leave the room if the resident became combative or resistant. Facility documentation stated that the resident complained through the translator that a nurse aide was rough during care. The documentation further stated that during the care episode the resident was very agitated, swinging arms, and intentionally striking the nurse aide. The nurse aide’s witness statement reported that the bed alarm was sounding because the resident was attempting to get out of bed, that the resident struck the aide multiple times while the aide attempted to wash the resident’s body, threw a washrag across the room, and repeatedly swung arms while the aide tried to brush the resident’s hair. The Nursing Home Administrator confirmed that the interventions intended to reduce the resident’s combativeness were not implemented.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into a potential case of resident abuse and/or neglect involving a resident who sustained an injury during care. The resident, who had a history of cerebral infarction and right-sided dominant impairment, required moderate assistance for activities of daily living and transfers. The incident occurred when the resident, while being assisted by a nursing aide, became weak and fell, resulting in a laceration that required sutures. The facility's investigation was incomplete, as it did not include critical details such as the length of time the resident was standing, the location of the wheelchair at the time of the fall, interviews with the resident's roommates, or an assessment of the bedframe structure. Statements from staff members provided conflicting information about the resident's care needs, with some indicating the use of a mechanical lift and two-person assistance for transfers, while others noted the resident could stand with one-person assistance. The facility's policies on reporting and investigating incidents, as well as abuse prevention, were not adequately followed. The policies require immediate examination of the resident, completion of an investigation report, and determination of reasonable cause for abuse. However, the investigation lacked comprehensive interviews and assessments, failing to meet the facility's standards for thoroughness and accuracy.
Failure to Update Resident Care Plan for Toileting Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically related to incontinent care. The facility's policy requires that care plans include measurable objectives and timetables to meet the resident's needs, derived from a thorough analysis of comprehensive assessments. However, the care plan for the resident in question did not reflect the resident's preferences and proper safe instructions regarding toileting needs, which included the preference to be toileted at bedside. The resident, who entered the facility with diagnoses including cerebral infarction, hemiplegia, and hemispheres, required moderate assistance for activities of daily living and used a wheelchair. Despite having an intact cognitive status, as indicated by a BIMS score of 14, the resident sustained an injury while receiving toileting care at bedside. The investigation concluded that it was within the resident's rights to choose to be toileted at bedside, yet the care plan was not updated to reflect this preference. Interviews with facility staff confirmed that the resident's care plan had not been updated with the resident's preferences and proper safe instructions regarding toileting needs. This oversight indicates a failure to adhere to the facility's policy of revising care plans as information about the resident's condition changes, thereby not fully addressing the resident's physical, psychosocial, and functional needs.
Failure to Properly Label and Store Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation of the kitchen, it was found that several plastic bags containing hamburger and hotdog buns were not labeled with the date delivered or the best by date. One of the plastic bags containing hamburger buns had a sticker with the delivery date of 10/13, but the best by date was not written on the sticker. Additionally, another plastic bag containing hamburger buns was observed to have grayish green powdery matter at the bottom of the buns, indicating potential spoilage. The Director of Dietary, Employee E3, confirmed these observations during an interview conducted at the time of the investigation. Employee E3 acknowledged that all bags should have been labeled with the delivery date and best by date, as per the facility's policy on receiving and safe food handling procedures. Following the observation, Employee E3 removed and discarded the four bags of buns that were not properly labeled and showed signs of spoilage.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their own policy on readmission. The resident, who was of Korean descent and had been admitted for long-term care due to conditions such as anxiety, dementia, diabetes, hypertension, and depression, was transferred to the hospital for a change in mental status. During the hospital stay, the resident was diagnosed with dementia with behavioral disorder, depression, anxiety, and tested positive for COVID-19 without symptoms. Despite the facility having available beds, there was no documentation of communication with the resident's responsible party regarding readmission plans. Interviews with the Nursing Home Administrator, Director of Nursing, and Admissions Director confirmed the lack of communication and documentation in the clinical record about the resident's readmission. The facility's policies required adherence to CDC guidelines for COVID-19 management, which included accepting residents with COVID-19 under specific precautions. However, the facility did not follow through with these policies, resulting in the resident not being readmitted post-hospitalization.
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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 | 2 mi | ★★★★★ | 19 | 0 |
| Willowbrooke Court Skilled Care Center At Brittany | 2.1 mi | ★★★★★ | 0 | 0 |
| Elm Terrace Gardens | 2.1 mi | ★★★★★ | 4 | 0 |
| St Mary Center For Rehabilitation & Healthcare | 2.3 mi | ★★★★★ | 15 | 0 |
| Willowbrooke Ctskdcarectr Atnormandy Farms Estates | 2.4 mi | ★★★★★ | 2 | 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.