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 St Mary Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe and sanitary environment in the main kitchen and on one nursing unit. The mop sink in the kitchen janitors' closet was clogged with black sludge around its base, and a front sink in a resident room was clogged with brown residue, indicating inadequate environmental cleanliness and maintenance.
Food Storage and Sanitation Deficiencies in Dietary Department: Surveyors observed improper food storage and unsanitary conditions in the dietary area, including prepackaged water cups touching apples, an opened undated package of potato salad, a crinkled piece of wax paper between a shelf and wall, and a reach-in cooler with dried food debris and white dried liquid inside. They also found a pan of applesauce dated beyond the facility’s stated holding period, a mop in dirty water, a wringer with a thick dark substance, and a sticky residue on a shelf below the juice dispenser.
Call bells were left out of reach for four residents whose care plans directed staff to keep the devices within easy reach. Residents with dementia, muscle wasting, diabetes, cataracts, and other conditions were observed with call bells on the floor, under the bed, or clipped to the bed frame or sheet in positions they could not reach, and several residents stated they did not know where the call bell was. The DON stated the call bells should have been within reach of each resident.
A resident with muscle weakness and anxiety was not provided activities in accordance with her preferences and choice. She was alert and oriented, used a wheelchair, and said attending church and group activities were very important to her, but she reported staff did not wake her early enough for church services and she was observed upset and in a gown. Her care plan and activity assessment documented that religion and church attendance were important and that she actively enjoyed church and group activities, and the DON confirmed her preference to be dressed early for church.
Inaccurate MDS Assessments for Oxygen, Antipsychotic, and Hospice Services. A resident receiving O2, a resident with schizophrenia receiving olanzapine, and a resident on hospice all had MDS entries that failed to reflect their current tx during the review period. The Administrator confirmed the MDSs were inaccurate.
A facility failed to document interdisciplinary care plan reviews within 7 days after comprehensive MDS assessments for three residents. Record review showed multiple quarterly, annual, and significant change MDS assessments for the residents, but no documentation of required care plan meetings. The Administrator confirmed there was no documentation that interdisciplinary care conferences were conducted for the affected residents.
Failure to Follow Physician Orders for Medication Administration and Daily Weights: Staff failed to follow physician orders for two residents. One resident with dementia and anxiety had an order for midodrine for hypotension, but the MAR showed doses were withheld without documented physician instruction. Another resident with HTN and CHF had an order for daily weights, but the record lacked documentation that weights were obtained on several scheduled days. The DON confirmed both failures during interview.
Failure to provide restorative ambulation services for a resident with muscle wasting and a hx of falls. The resident was cognitively impaired, needed staff assist with ADLs, and PT recommended a restorative program for ambulation with a walker and wheelchair follow-up 3x/week after therapy discharge. Nursing documentation did not support that the resident received the ordered restorative services, and the DON confirmed there was no documentation that the resident was ambulated as recommended.
Failure to follow fall precautions for three residents at risk for falls. Residents with dementia, muscle wasting, seizures, and stroke-related weakness were cognitively impaired and needed staff help with bed mobility and transfers. Their care plans called for the bed to be in the lowest position and fall mats to be placed on both sides of the bed, but observations found mats missing, misplaced, folded, or only on one side, and two residents’ beds were not in the lowest position. An aide stated she was not aware the resident needed mats on both sides, and the DON confirmed the expected interventions.
Failure to follow a resident’s meal ticket resulted in a meal being served without the gravy listed for the entree. The resident, who was alert and able to make needs known and had diagnoses including anxiety, GERD, and depression, stated that meals did not match the ticket and that he did not receive foods he liked. The tray was observed with pork loin, brussels sprouts, and potatoes, but no gravy, and the Administrator stated dietary did not follow the meal ticket.
Failure to provide ordered adaptive drinking cups for a resident with stroke, dysphagia, and dementia. Speech therapy directed use of a dysphagia cup, and the meal ticket called for two green dysphagia cups with meals, but observations showed only one cup on the tray while milk, juice, and coffee were served. An NA stated only one cup came from the kitchen, and the RD confirmed two cups were needed for the resident’s different liquids.
Failure to use Enhanced Barrier Precautions during a resident transfer. A resident with dysphagia, muscle weakness, and an enteral feeding tube had a care plan requiring gloves and gowns for close contact interactions, but an RN and a nurse aide transferred the resident from bed to wheelchair without wearing PPE. The RN acknowledged the lapse, and the DON confirmed PPE should have been worn.
A facility failed to maintain a safe, sanitary, and comfortable environment on two nursing units when a resident lift and three med carts were observed with dirty wheels containing knotted, intertwined thick [NAME] of hair and debris. The deficiency was cited under 28 Pa. Code 201.14(a) and 201.18(b)(3).
The facility failed to post accurate and current nurse staffing information. During a tour, surveyors observed that no staffing data was posted, and the Administrator later confirmed that staffing data was not posted in the facility.
The facility failed to properly store and date food items in the dietary department, as observed during a survey. Undated opened bags of food were found in the freezer, and expired dairy products were present in the cooler. The Food Service Director confirmed these items should have been dated and expired items removed, indicating non-compliance with the facility's food safety policy.
The facility failed to develop comprehensive care plans for three residents, each with cognitive impairments and other diagnoses. Despite assessments indicating the need for specific interventions, the care plans lacked these necessary components. The DON confirmed the absence of documented evidence addressing these care areas.
The facility failed to follow physician's orders for medication administration and monitoring for four residents. Medications were administered outside prescribed blood pressure parameters, and one resident was not weighed as ordered. The DON confirmed these discrepancies.
Clogged and Unsanitary Sinks in Kitchen and Resident Room
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, sanitary, and comfortable environment in the main kitchen and on one nursing unit. During an observation period from 12:00 p.m. to 1:00 p.m. on January 29, 2026, the mop sink in the main kitchen janitors' closet was found to be clogged with an accumulation of black sludge around the base of the sink. In addition, in a resident room identified as [ROOM NUMBER], the front sink was observed to be clogged with a brown residue. These conditions were cited under 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(3)(e)(2.1) related to the licensee’s responsibility and management requirements for maintaining a safe, clean, and comfortable environment.
Food Storage and Sanitation Deficiencies in Dietary Department
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in the dietary department. During review of the facility policy on labeling and dating food, prepared foods held at 41 degrees Fahrenheit or lower were required to be discarded after seven days. During the dietary department tour, surveyors observed two cups of prepackaged water in the juice box directly touching apples in a bowl, an opened large package of potato salad in walk-in cooler 1 that was not dated, and a crinkled piece of wax paper between the food shelf and wall in walk-in cooler 2. The reach-in cooler had dried food debris on the outside, a large area of white dried liquid splattered along the inside of the door, white dried liquid along the inside bottom, and a pan of applesauce dated December 4, 2025. In the closet, a mop in a bucket with dirty water was not in current use, the mop wringer had a thick dark substance along all the holes, and a shelf at the juice dispenser had a dried sticky substance below the dispenser area.
Call Bells Left Out of Reach for Four Residents
Penalty
Summary
The facility failed to ensure that call bells were within easy reach for four sampled residents: Resident 30, Resident 68, Resident 74, and Resident 102. Resident 30 had diagnoses including dementia, cerebral infarction, acute respiratory failure, and cataracts in both eyes; the MDS showed she could make her needs known, needed some assistance with ADLs, and was at risk for falls. Her care plan directed staff to keep the call bell within easy reach and reinforce its use, yet observations found the call bell on the floor under the bed and later clipped to the sheet close to the floor and out of reach. During interviews, Resident 30 stated she did not know where the call bell was. Resident 68 had diagnoses including dementia and muscle wasting, was able to make her needs known, was dependent for ADLs, and was at risk for falls; her care plan also directed staff to keep the call bell within easy reach. Observations showed the call bell under the bed and later clipped to the sheet close to the floor and out of reach, and the resident stated she did not know where it was. Resident 74 had diagnoses including anxiety, muscle wasting, and diabetes, required assistance with ADLs, and was at risk for falls; observations showed the call bell clipped to the sheet at the very top of the bed out of reach, and the resident stated she used the call bell but did not know where it was. Resident 102 had diagnoses including dementia, cataracts, and irritable bowel syndrome with diarrhea, required assistance with ADLs, and was at risk for falls; observations showed the call bell clipped to the metal bed frame at the top of the bed facing the floor and out of reach. The DON stated the call bells should have been within reach of each resident.
Failure to Support Resident's Preferred Church Attendance
Penalty
Summary
The facility failed to provide activities in accordance with resident preferences and choice for one resident who had diagnoses of muscle weakness and anxiety. The resident’s MDS assessment indicated she was alert and oriented, used a wheelchair, was dependent on staff for care, and stated that it was very important for her to attend church and do things with groups of people. During interview, the resident said she could not attend church services on Sunday, Monday, and Tuesday at 11:00 a.m. because staff did not wake her up early, and she was observed in a gown, upset and anxious, stating that attending church was very important and that she had told staff she preferred to be dressed before 9:00 a.m. to attend church. The December 2025 activities calendar showed church services scheduled every day at 11:00 a.m., and the care plan indicated her religion was important and staff were to assist her to religious services. An activity assessment also noted that she actively attended church services and enjoyed many group activities, with a goal to maintain her current level of participation in preferred leisure interests. The DON confirmed that the resident preferred to be dressed early and that attending church was important.
Inaccurate MDS Assessments for Oxygen, Antipsychotic, and Hospice Services
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current status of three residents. Resident 1 began receiving oxygen therapy on November 30, 2025, but the MDS assessment dated [DATE] incorrectly stated in Section O that the resident was not receiving oxygen therapy during the previous seven days. Resident 9 had diagnoses including schizophrenia and had been receiving the antipsychotic medication olanzapine since August 30, 2025; the October 2025 MAR showed olanzapine was administered during the MDS review period, yet the MDS assessment dated [DATE] incorrectly indicated in Section N that the resident did not receive an antipsychotic medication in the review period. Resident 23 had been receiving hospice services since April 24, 2024, but the MDS assessment dated [DATE] incorrectly stated in Section O that the resident was not receiving hospice services during the previous seven days. In an interview on December 16, 2025, at 9:27 a.m., the Administrator confirmed that the MDS assessments for Residents 1, 9, and 23 were inaccurate.
Failure to Review Care Plans After Comprehensive Assessments
Penalty
Summary
The facility failed to review the care plan within seven days after completion of the comprehensive assessment for three sampled residents. Clinical record review showed that Resident 5 had quarterly MDS assessments completed on February 11, 2025, August 6, 2025, and November 6, 2025, along with an annual MDS assessment completed on May 12, 2025. There was no documentation to support that an interdisciplinary care plan meeting was conducted within the required timeframe after these assessments to review the care plan. Clinical record review also showed that Resident 30 had quarterly MDS assessments completed on April 15, 2025, July 23, 2025, and August 15, 2025, and an annual MDS assessment completed on November 14, 2025, with no documentation supporting an interdisciplinary care plan meeting within the required timeframe. Resident 68 had a quarterly MDS assessment completed on June 4, 2025, an annual MDS assessment completed on August 29, 2025, and a significant change MDS assessment completed on November 15, 2025, and there was likewise no documentation that the care plan was reviewed within the required timeframe. In an interview on December 19, 2025, at 12:12 p.m., the Administrator confirmed there was no documentation that interdisciplinary care conferences were conducted after completion of the comprehensive assessments for Residents 5, 30, and 68.
Failure to Follow Physician Orders for Medication Administration and Daily Weights
Penalty
Summary
The facility failed to implement physician orders for two residents. One resident had diagnoses of dementia and anxiety, and a physician ordered midodrine hydrochloride twice daily for hypotension, with instructions not to administer it if systolic blood pressure was 130 mm/Hg or higher. Review of the MAR showed the medication was withheld when the resident’s SBP was below 130 mm/Hg on three occasions in October 2025, 14 occasions in November 2025, and 10 occasions in December 2025, and there was no documented evidence that the physician had instructed staff to hold the medication. The DON confirmed during interview that the medication should have been administered and that there was no documented evidence of a physician instruction to hold it. Another resident, admitted with diagnoses including hypertension and congestive heart failure, had a physician order on November 15, 2025, for daily weights. Review of the weight record showed no documented evidence that the resident was weighed on November 23 and 29, 2025, and December 2 and 11, 2025. During interview, the DON confirmed there was no documented evidence to support that staff weighed the resident in accordance with the physician’s order.
Failure to Provide Restorative Ambulation Services
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve range of motion and mobility for one resident. Resident 112 had diagnoses including muscle wasting and a history of falling, and the MDS indicated the resident was cognitively impaired and needed staff assistance with ADLs. After therapy discharge, the physical therapist documented that the resident required staff assistance for transfers and ambulation and recommended a restorative nursing program, with training and instruction provided to the resident and primary caregivers. A restorative recommendation dated November 10, 2025, specified that staff were to assist the resident to walk 90 feet or less with a walker while following with a wheelchair three times a week. Nursing staff on the 300 hallway were educated about the functional maintenance/restorative nursing program, but review of nursing documentation from November 20, 2025, through December 19, 2025, showed no documentation that the resident received the recommended restorative nursing services. In interview, the DON confirmed there was no documentation supporting that the resident was ambulated as recommended after discharge from therapy.
Failure to Follow Fall Precautions for Three Residents
Penalty
Summary
The facility failed to implement fall safety interventions for three residents who were identified as being at risk for falls. Resident 68 had diagnoses including dementia and muscle wasting, was cognitively impaired, and required staff assistance for bed mobility and transfers. The resident’s care plan directed that the bed be kept in the lowest position and that fall mats be placed on each side of the bed while the resident was in bed, but observations showed the resident in bed without fall mats on the floor and with the bed not in the lowest position on multiple occasions. During one observation, a nurse aide raised the bed into a higher position and stated she was not aware the resident should have fall mats on each side of the bed. Resident 98 had diagnoses including seizures and left-sided weakness or paralysis due to a stroke, was cognitively impaired, and required staff assistance for bed mobility and transfers. The resident’s fall assessment identified the resident as at risk for falls, and the care plan directed that fall mats be in place on the floor when the resident was in bed. Observations showed one fall mat on the right side of the bed and another fall mat against the wall on the right side of the bed. Resident 112 had diagnoses including dementia and muscle wasting, was cognitively impaired, and required staff assistance for bed mobility and transfers. The resident’s care plan directed that the bed be in the lowest position and that fall mats be in place while the resident was in bed, but observations showed one folded fall mat on the floor on the right side of the bed, no second mat on the other side, and the bed not in the lowest position. The DON confirmed that the fall mats should have been in place on both sides of the bed for Residents 68, 98, and 112, and that the beds should have been in the lowest position for Residents 68 and 112 while they were in bed.
Failure to Follow Meal Ticket for Resident’s Gravy Preference
Penalty
Summary
The facility failed to accommodate a resident’s food preferences by not providing the gravy listed on the meal ticket for lunch. Review of the weekly menu showed that the lunch meal included herb rubbed pork loin with gravy, boiled new potatoes, brussels sprouts, and glazed pear cobbler. Resident 9, who was admitted with diagnoses including anxiety, GERD, and depression, had an MDS assessment indicating he was alert and able to make his needs known. During an interview, the resident stated that his meals did not match what was on his ticket and that he did not receive foods he liked that were listed. When his lunch tray was observed on his bedside table, it contained herb rubbed pork loin, brussels sprouts, and boiled new potatoes, but no gravy on the meat. The resident stated he wanted gravy as listed on the meal ticket and did not want to eat the meat without it. The tray card indicated he was on a regular diet and was to receive gravy at the meal. The Administrator later stated that the dietary department did not follow the resident’s meal ticket and should have provided the gravy.
Failure to Provide Ordered Adaptive Drinking Cups
Penalty
Summary
The facility failed to ensure that adaptive eating equipment was provided to a resident who needed it. Resident 15 had diagnoses including stroke, difficulty swallowing food or liquids, and dementia, and the Minimum Data Set indicated the resident was cognitively impaired. Speech therapy discharge instructions stated that the resident was to use a dysphagia cup for drinking liquids, and the meal ticket specified that two large green dysphagia cups were to be provided with meals. However, observations on three separate occasions showed only one green dysphagia cup on the resident’s lunch tray. During one observation, a Nursing Assistant assisted the resident with drinking milk from the dysphagia cup, and the resident reached for and held the cup while drinking. An unopened juice cup and an unopened cup of coffee were also on the tray and were not in adaptive cups. The Nursing Assistant stated that two green dysphagia cups were supposed to be on the meal tray but only one was received from the kitchen, and the registered dietitian confirmed that two green dysphagia cups should have been on each meal tray for the resident’s different liquids.
Failure to Use Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to follow its infection prevention and control policies for one resident who required Enhanced Barrier Precautions. The resident was admitted with dysphagia and muscle weakness, and the MDS showed an enteral feeding tube. The care plan directed staff to wear gloves and gowns during close contact interactions. During an observation, an RN and a nurse aide transferred the resident from the bed to a wheelchair using a mechanical device, but neither staff member wore gloves or gowns. The RN stated she should have worn a gown and gloves during the transfer, and the DON later confirmed that staff should have worn gloves and a gown during the transfer.
Dirty equipment wheels observed on nursing units
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment on two of four nursing units, St. [NAME] and St. [NAME]. During observation throughout the facility, a lift used to transfer residents from surface to surface was seen with dirty wheels containing knotted and intertwined thick [NAME] of hair and debris. Three medication carts were also observed with dirty wheels containing knotted and intertwined thick [NAME] of hair and debris. The cited deficiencies were referenced under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(b)(3) Management.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information. During a tour of the facility conducted between December 16 and 18, 2025, between 9:30 a.m. and 2:00 p.m., surveyors observed that no staffing data was posted. In an interview on December 18, 2025, at 2:25 p.m., the Administrator confirmed that staffing data was not posted in the facility.
Failure to Properly Store and Date Food Items
Penalty
Summary
The facility failed to adhere to its policy on food safety, specifically regarding the proper storage and dating of food items in the dietary department. During a tour of the dietary department, surveyors observed several instances of non-compliance. In the freezer, opened bags of onion rings, raw cookies, and fish sticks were found without dates. Additionally, a box labeled for diced chicken contained opened bags of breaded meat and diced chicken, both undated. In the dairy cooler, a container of sour cream and multiple cartons of milk were found past their use-by dates, and a parmesan cheese container was covered with red food debris. The production walk-in cooler contained an opened case of orange juice and a package of hot dogs, both undated. In dry storage, an opened package of sprinkles had dried flour on it, and a package of tortillas was undated. The tray line milk cooler also contained expired milk cartons. The Food Service Director confirmed these items should have been dated and expired items removed, indicating a failure to maintain sanitary conditions and proper food storage practices.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, as identified in their comprehensive assessments. Resident 6, diagnosed with metabolic encephalopathy and mild cognitive impairment, had a Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicating that cognitive loss should be addressed in the care plan. However, there was no evidence of interventions for cognitive loss in the current care plan. Similarly, Resident 9, with diagnoses including aphasia, dementia, and brain injury, had an MDS CAA summary noting the need to address cognitive loss and dementia. Despite a quarterly MDS summary indicating limited cognition, the care plan lacked interventions for these issues. Resident 61, diagnosed with dementia and brain injury, also had an MDS CAA summary highlighting the need to address cognitive loss and communication deficits. However, the care plan did not include interventions for these areas. The Director of Nursing confirmed the absence of documented evidence addressing the identified care areas in the care plans during an interview. This deficiency was noted under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Follow Physician's Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to implement physician's orders for four residents, leading to medication administration errors and lack of required monitoring. Resident 28, diagnosed with hypertension and heart failure, received atenolol twice in January 2025 when their systolic blood pressure (SBP) was below the prescribed threshold of 120 mm/Hg. Similarly, Resident 32, with heart failure, hypertension, and chronic kidney failure, was administered nifedipine and metoprolol tartrate multiple times in December 2024 and January 2025 despite their SBP being below 120 mm/Hg. Additionally, Resident 32 was not weighed as ordered on specified dates in December 2024 and January 2025. Resident 55, who had heart failure, was given carvedilol three times in January 2025 when their SBP was below the required 100 mm/Hg. Resident 258, diagnosed with hypotension, received midodrine four times in January 2025 when their SBP exceeded the maximum limit of 130 mm/Hg. The Director of Nursing confirmed these discrepancies, acknowledging that medications were administered outside the established parameters and that Resident 32 was not weighed as ordered.
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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) |
|---|---|---|---|---|
| Elm Terrace Gardens | 0.7 mi | ★★★★★ | 4 | 0 |
| Harborview Rehabilitation And Care Center At Lansd | 0.8 mi | ★★★★★ | 19 | 0 |
| Montgomeryville Skilled Nursing And Rehabilitati | 1.3 mi | ★★★★★ | 0 | 0 |
| Gwynedd Healthcare And Rehabilitation Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Horsham Center For Jewish Life | 3.3 mi | ★★★★★ | 7 | 0 |
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