Cycle 1
Health 2025-03-27 · Fire 2025-03-27
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lansdale, PA
Elm Terrace Gardens
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
660 North Broad Street, Lansdale, PA
(215) 361-5600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-06-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.20
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,118
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9880
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.48
Baseline 20.50% · Performance 19.36% · Measure score 4.48 · Achievement 4.48 · Improvement 2.79
Healthcare-associated infections
0
Baseline 6.57% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.10
Performance 46.91% · Measure score 4.10 · Achievement 4.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.99
Baseline 4.07 hours · Performance 4.50 hours · Measure score 4.99 · Achievement 4.99 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.14% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 185 · Observed rate 11.35% · Lower 95% interval 8.14% |
| Discharge to community | 68.87% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 160 · Observed rate 61.88% · Lower 95% interval 62.14% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.23% |
95.27%
4 pts better
|
Numerator 129 · Denominator 130 |
| Falls with major injury | 1.54% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 130 |
| Discharge self-care score | 43.4% |
53.69%
10.3 pts worse
|
Numerator 46 · Denominator 106 |
| Discharge mobility score | 46.23% |
50.94%
4.7 pts worse
|
Numerator 49 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 2.31% |
2.29%
About the same
|
Numerator 3 · Denominator 130 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 7.87% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 1.74% |
8.2%
6.5 pts worse
|
Numerator 5 · Denominator 288 |
| Staff flu vaccination coverage | 99.47% |
42%
57.5 pts better
|
Numerator 372 · Denominator 374 |
| Discharge function score | 44.34% |
56.45%
12.1 pts worse
|
Numerator 47 · Denominator 106 |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 20 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 96 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 1.33% |
25.2%
23.9 pts worse
|
Numerator 1 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 63.3% |
86.9%
23.6 pts worse
|
93.4%
30.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.5% · Q2 62.2% · Q3 64.3% · Q4 63.4% · 4Q avg 63.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
93.5%
8.9 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.2%
2.4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.9% · Q3 4.8% · Q4 2.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.5%
3.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 10.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
19.9%
7.9 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 9.7% · Q3 6.7% · Q4 11.1% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.0% |
18.7%
17.7 pts better
|
16.7%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 55.0% |
19.6%
35.4 pts worse
|
16.3%
38.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 55.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 45.6% |
18.3%
27.3 pts worse
|
14.9%
30.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 38.5% · Q3 52.2% · Q4 54.5% · 4Q avg 45.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.1% · Q3 1.8% · Q4 2.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.7%
2.4 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.5% · Q3 5.3% · Q4 5.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
26.4%
1.7 pts better
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 26.3% · Q3 12.1% · Q4 48.5% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.3%
1.2 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.7% · Q3 1.4% · Q4 5.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.4% |
68.9%
40.5 pts worse
|
81.7%
53.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 31.5% · Q3 31.6% · Q4 33.3% · 4Q avg 28.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.8%
1.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 2.0% · Q4 1.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.4% |
68.7%
29.3 pts worse
|
79.7%
40.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 39.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
23.1%
4.8 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 23.0% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-06-01 · Fire 2023-06-01
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-05-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-05-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-05-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-25
C · Minimal harm
2024-05-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-25
E · Potential for more than minimal harm
2023-06-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-11
C · Minimal harm
2023-06-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-21
D · Potential for more than minimal harm
2024-05-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-10
D · Potential for more than minimal harm
2023-06-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-01
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-07-05
C · Minimal harm
2023-06-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-05
Penalties and ownership
What sits behind the stars
Ownership
Burns, James
Corporate Director · Individual
Butterworth, Nancy
Corporate Director · Individual
Campbell, Craig
Corporate Director · Individual
Covington, Craig
Corporate Director · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Fuller, Mary
Corporate Director · Individual
Glantz, Natalie
Corporate Director · Individual
Hafeez, Madeeha
Operational/Managerial Control · Individual
Helpa, Donald
Corporate Director · Individual
Kastle, Kerry
Corporate Director · Individual
Krathanzel, Eric
Corporate Director · Individual
Mathues, Harold
Corporate Director · Individual
Messner, Diane
Corporate Director · Individual
Meyers, Jennifer
Operational/Managerial Control · Individual
Meyers, Jennifer
Corporate Officer · Individual
Murphy, Timothy
Operational/Managerial Control · Individual
Murphy, Timothy
Corporate Officer · Individual
Parola, John
Corporate Director · Individual
Parvin, Robert
Operational/Managerial Control · Individual
Parvin, Robert
Corporate Officer · Individual
Phillips, Matthew
Operational/Managerial Control · Individual
Rice, Karen
Corporate Director · Individual
Tatum, Kathryn
Corporate Director · Individual
Wagner, Linsay
Operational/Managerial Control · Individual
Wagner, Linsay
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Harborview Rehabilitation And Care Center At Lansd
Lansdale, PA
1-star overall rating with 1-star inspections with $191,228 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
St Mary Center For Rehabilitation & Healthcare
Lansdale, PA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Montgomeryville Skilled Nursing And Rehabilitati
Montgomeryville, PA
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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