Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Harborview Rehabilitation And Care Center At Lansd during CMS and state inspections, most recent first.
Meal trays were not consistently removed in a timely manner for a resident. Observations showed lunch and breakfast trays left at the bedside for hours after delivery, with food items such as meatloaf, fish, vegetables, milk, oatmeal, and cereal still present. An LPN confirmed the delivery times, and the FAC and DON acknowledged the trays were not consistently removed promptly.
Facility assessment did not include the needs of the bariatric resident population. The census showed 117 residents, and the facility identified 10 residents with morbid obesity who required bariatric beds, wheelchairs, mechanical lifts, and other bariatric-specific equipment. The assessment did not reference their care needs, specialized supplies, or staffing resources, even though the facility’s bariatric policy called for a safe environment, bariatric equipment, two-person assists, and staff training in transfers, mobility, and evacuation preparedness. The NHA confirmed the bariatric staffing and care planning needs were not evaluated in the most recent assessment.
The facility failed to ensure that 16 nurse aides completed the required 12 hours of annual nursing-related in-service training based on resident needs. Record review showed missing training in dementia care, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, and cultural competency, and the DON confirmed the lapse.
A resident with cervical disc disorder and edentulism did not have care plans developed or implemented for recommended cervical ROM exercises or dental needs. Staff confirmed the absence of a restorative nursing program, no documentation of ROM exercises, and no care plan addressing denture use or the resident's complaints of pain with dentures.
A resident at a dining table was left without a meal while two other residents were already eating, and the meal tray was placed out of reach in the center of the table. The resident required mechanical soft solids, thin liquids, aspiration precautions, and 1:1 feeding assistance, but staff said she had not been served because she was a feeder, using that term in front of staff and other residents. The NHA confirmed the resident had not yet received dining assistance.
The facility failed to timely provide NOMNCs to two residents when Medicare-covered services were ending. Review of records showed the required CMS-10123 notices were not delivered at least two calendar days before coverage ended for one resident who was discharged and another resident who remained in the facility. Social Services confirmed the notices were not provided on time.
A resident's room was observed with dirt around the baseboards, a visibly soiled floor, and a hole in the wall near an outlet, and the NHA confirmed the findings. The resident said she hides her belongings because she does not have a locking drawer, and eleven alert and oriented residents in a group meeting reported they also lacked locked drawers for personal items. The MDS stated locking drawers are only provided if requested on admission and confirmed the listed residents did not have them.
Grievance forms were not available or accessible for anonymous submission on the 2nd and 3rd floor nursing units. Residents reported they did not know where to find grievance forms or submission boxes, and a tour confirmed that forms and grievance boxes were not present on those units. Staff stated forms were only available upon request behind the nursing station, and the NHA confirmed residents who could not leave the unit would have to give grievances to staff or the administrator.
Late Completion and Submission of Discharge MDS Assessments: The facility failed to complete and submit discharge MDS assessments within the required timeframe for two residents. Both residents were discharged to the hospital, the discharge MDSs were initiated, but the RNAC confirmed that each assessment was completed and submitted late.
A resident with cervical disc disorder with myelopathy and lumbar region involvement was discharged from OT with a recommendation for cervical ROM, but the record had no documented evidence that the ROM was provided. The DON confirmed there was no Restorative Nursing Program in place and no documentation that the cervical ROM was performed.
Dietary restrictions and allergies were not followed for two residents. One resident with intact cognition and documented allergies to strawberries and tree nuts was served cake with icing even though the cake was not identified to the resident, the resident stated he was allergic to all nuts, and no alternate dessert was offered. Another resident with a diet order for no beef, no pork, and no straws was observed receiving a tray with a straw and later a tray that included pork over rice and a straw; an LPN confirmed the meal was served despite the restrictions.
A facility failed to ensure working call bells were available for two residents. One resident with knee pain and difficulty walking was observed in bed yelling for help, and both residents had bedside call bell outlets with missing or damaged cords. The second floor UM confirmed the call bells were non-functional.
Survey results were not readily accessible to residents, families, and visitors on the 1st, 2nd, and 3rd floor units. A resident group reported they did not know where the survey binder was located, and an observation found it in the main lobby in a black unlabeled binder that did not contain survey results beyond February 2024. The NHA confirmed the state survey results were not readily accessible for review.
Two residents with behavioral and mental health diagnoses engaged in close interactions, including kissing and being alone together, which were observed and reported by staff but not documented in their clinical records. Despite staff awareness and intervention, the facility failed to maintain complete and accurate documentation of these events as required by policy.
A resident with psychosis and schizophrenia, who expressed dissatisfaction with the facility environment and food, was able to leave the facility without a comprehensive elopement care plan in place. The resident was later found offsite and returned without injury. Facility leadership confirmed the absence of a person-centered care plan addressing elopement risk.
The facility failed to serve hot beverages at safe temperatures, resulting in a burn injury to a resident. Additionally, inadequate supervision led to another resident with dysphagia consuming inappropriate food, causing a choking incident and aspiration pneumonia. These deficiencies highlight lapses in adherence to safety protocols and supervision requirements.
The facility failed to store drugs and biologicals according to professional standards in two medication storage rooms. On the 2nd floor, Latanoprost eye drops requiring refrigeration were improperly stored in a medication cart. On the 3rd floor, expired nutritional supplements and medications were found, including Glucerna and Simethicone drops. These deficiencies were confirmed with staff members.
The facility failed to promptly resolve grievances related to billing, room changes, and missing items for several residents. A resident with heart failure experienced delays in room change requests and issues with missing orthopedic shoes, while another resident with multiple sclerosis faced unresolved billing concerns. Additionally, residents were not informed about the status of the activity van, leading to dissatisfaction and a violation of resident rights.
The facility failed to provide timely podiatry care for two residents, one with Type II Diabetes and another with multiple sclerosis, both requiring regular foot care due to their conditions. Despite recommendations for follow-up treatment every 60 days, no further podiatry appointments were scheduled after July 2024, as confirmed by the DON.
A resident with dysphagia and other health conditions choked on a hoagie due to insufficient supervision during meals, despite having a care plan requiring supervision. The facility lacked enough nursing staff to oversee residents with behavioral health needs, resulting in the resident developing aspiration pneumonia.
The Nursing Home Administrator and DON failed to manage hot beverage temperatures, resulting in a resident burn. Coffee was served at unsafe temperatures, contrary to facility policy, leading to a blister on a resident's hip. Staff were unaware of the policy and did not check temperatures before serving.
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy. During an observation, it was noted that there was no signage or PPE for residents with specific medical conditions necessitating such precautions, including those with Foley catheters, feeding tubes, and infections. An interview confirmed the lack of policy implementation.
The facility did not maintain safe water temperatures across all floors, as reported by residents and confirmed by surveyors. Two residents experienced temperature fluctuations, with one noting a sudden increase while showering. The facility lacked a specific water temperature policy, relying on state regulations. Surveyors found temperatures exceeding the 110-degree limit, and the Maintenance Director identified a faulty regulator as the issue.
The facility failed to ensure that a staff member completing the MDS was licensed to practice nursing in Pennsylvania. Employee E15, working remotely from outside the U.S., completed and signed multiple sections of the MDS for several residents without a valid nursing license. Interviews revealed a lack of awareness and documentation regarding her licensing status, with the Director of Nursing and Administrator unable to provide a copy of her license.
A facility failed to provide ASL translation for a resident's representative during a care plan meeting, despite the representative's need for such services due to being deaf. The facility's policy only accommodated translation services if the resident required it, leading to a deficiency in communication. Staff communicated with the representative through writing, but did not provide a sign language interpreter, as the facility was unwilling to cover the associated costs.
The facility failed to notify the State Long Term Ombudsman of emergency transfers and discharges for three residents. One resident was discharged to the hospital and did not return, another was discharged and cut off by insurance, and a third was discharged, readmitted, and discharged again without returning. The facility lacked a process for notifying the Ombudsman.
The facility failed to maintain functioning air conditioning units across all three nursing units, affecting resident rooms and dining areas. Observations revealed several PTAC units were non-functional, with issues such as not blowing cool air and having detached front panels. Residents reported discomfort due to warm room conditions. Facility documentation indicated multiple units required repairs, including cooling section and control box replacements.
Meal trays left at bedside for extended periods
Penalty
Summary
Meals were not consistently removed from a resident’s bedside in a timely manner, and food and beverages remained present well beyond the time the meals were delivered. On August 18, 2025, observations at 2:01 p.m. and 2:45 p.m. showed Resident R39’s lunch tray still at the bedside with meatloaf, potatoes, cauliflower, and milk more than two and a half hours after delivery. An LPN confirmed the lunch had been delivered between 11:30 a.m. and 12:00 p.m. that day. On August 19, 2025, Resident R39 was observed asleep with a meal tray still at the bedside containing fish, collard greens, and sweet potatoes, and the tray remained there during a follow-up observation at 2:15 p.m. On August 20, 2025, the resident’s breakfast tray was still at the bedside at 11:22 a.m. with milk, oatmeal, cereal, and a cookie, more than 3 hours after delivery. An LPN confirmed the breakfast had been delivered between 7:30 a.m. and 8:00 a.m. During an interview on August 21, 2025, the Facility Administrator and DON acknowledged that meal trays were not consistently removed in a timely manner.
Facility Assessment Did Not Address Bariatric Resident Needs
Penalty
Summary
The facility failed to include the needs of its bariatric resident population in the facility-wide assessment required to identify the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the facility census dated August 18, 2025, showed 117 residents, and documentation provided by the facility identified 10 residents with morbid obesity who required bariatric-specific equipment, including bariatric beds, wheelchairs, mechanical lifts, and related accessories to support safe care delivery. Review of the facility assessment tool dated August 5, 2025, showed no reference to the bariatric resident population, their care needs, or the specialized equipment, supplies, and staffing resources needed to care for them. The facility’s Bariatric Resident Guidelines, dated February 1, 2024, stated that bariatric residents are to receive a safe environment and appropriate care, including bariatric lifts, beds, gowns, shower chairs, and large BP cuffs, and that they require a two-person assist and staff training in transfers, mobility, and evacuation preparedness. During interview, the NHA confirmed the facility had obtained bariatric equipment as needed but acknowledged that staffing needs, care planning considerations, and resource requirements specific to the bariatric population had not been evaluated or included in the most recent assessment.
Failure to Complete Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to ensure that 16 nursing assistants employed since the last review period completed the required minimum of 12 hours of annual nursing-related in-service training based on resident needs. Record review showed that Employees E14 through E29 had not completed annual training in areas including dementia care of cognitively impaired residents, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, and cultural competency. During an interview, the DON confirmed that the facility had not ensured completion of the required annual in-service training for these nursing assistants.
Failure to Develop and Implement Care Plans for ROM and Dental Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing both range of motion (ROM) and dental needs for a resident diagnosed with Cervical Disc Disorder with Myelopathy. The resident was discharged from occupational therapy with recommendations for cervical ROM exercises, but there was no evidence that these exercises were performed or documented. Interviews with facility staff, including the Director of Nursing, confirmed that there was no restorative nursing program in place at the time and no care plan related to cervical ROM for the resident. Additionally, the resident was observed to be edentulous and not wearing dentures due to pain, instead gumming food during meals. The resident reported needing new dentures, and staff interviews confirmed the absence of a care plan addressing dental needs, denture use, or the resident's preferences and complaints regarding dentures. The Minimum Data Set (MDS) did not accurately reflect the resident's edentulous status, and there was no documentation or care planning for non-compliance with denture use or for the resident's dental discomfort.
Delayed Meal Service and Loss of Dignity at Dining Table
Penalty
Summary
The facility failed to ensure that all residents at a lunch table were served their meals at the same time and failed to maintain a resident's dignity in one of the dining rooms observed. During lunch service in the first-floor dining room, three residents were seated at one table. Two residents had already received their meals and were actively eating, while Resident R70 remained without a meal and the tray was placed in the center of the table, out of reach. When observed again later, the two other residents had finished eating, and Resident R70 still had not received the lunch meal, which remained untouched in the center of the table. Resident R70's meal ticket showed fish, potatoes, collard greens, and the care plan identified mechanical soft solids and thin liquids, with aspiration precautions and one-on-one assistance with feeding. The Food Service Manager stated that Resident R70 had not yet been served because she was a feeder and required assistance with eating, and this term was used in the presence of staff and other residents. The NHA confirmed that Resident R70 had not yet received assistance with dining.
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to timely provide Notices of Medicare Non-Coverage (CMS-10123) for two residents, R126 and R31. A review of facility documentation showed that Medicare services ended for R126 on April 2, 2025, and for R31 on April 30, 2025, but the required notice was not delivered at least two calendar days before Medicare-covered services ended. R126 was discharged to another facility, and R31 remained in the facility. Review of the NOMNC forms for both residents confirmed that the notices were not provided timely, and Social Services staff member E13 confirmed in interview on August 20, 2025, that the NOMNC was not provided timely for either resident.
Failure to Maintain Clean Room Conditions and Provide Locked Storage
Penalty
Summary
The facility failed to provide a clean, comfortable, homelike environment for one resident and failed to provide a locked drawer for personal belongings for twelve residents. On April 18, 2025, observation of one resident's room found significant dirt around the baseboards, a visibly soiled floor, and a hole in the wall near an outlet. The Nursing Home Administrator later confirmed the soiled floor, dirt, and hole in the wall. During interview, the resident stated she hides her belongings in the room to prevent losing them or someone taking them while she is at activities and said she did not have a locking drawer to feel comfortable leaving personal belongings in her room while she was away. In a resident group meeting, eleven alert and oriented residents reported they did not have a locked drawer to store and keep safe personal belongings. The Maintenance Director stated residents must request a locking drawer on admission and they are not provided automatically, and confirmed the listed residents did not have locking drawers.
Grievance Forms Not Accessible on Two Nursing Units
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible for anonymous submission on the second and third floor nursing units. During a resident group interview with eleven alert and oriented residents, the residents reported that they were unaware of where grievance forms were located and did not know the location of grievance or concern submission boxes for anonymous grievances. During a facility tour with the Nursing Home Administrator, it was confirmed that grievance forms were not available on the second or third floor nursing units. Nursing staff at the nursing station stated that grievance forms were available only upon request behind the nursing station. The Nursing Home Administrator confirmed that no forms were available on the second or third floor for residents to submit anonymous grievances and that no grievance or concern submission boxes were available on those units. The Administrator further stated that residents with wander guards or who were unable to leave the nursing unit would have to give their grievance to a staff member to place in the box on the first floor or give it directly to the administrator.
Late Completion and Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit discharge MDS tracking assessments within the required timeframe for two residents. Resident R121 was discharged to the hospital on May 11, 2025, and the discharge MDS was initiated, but the assessment was not completed until May 28, 2025 and was submitted the same day. Resident R29 was discharged to the hospital on July 16, 2025, and the discharge MDS was initiated that day, but the assessment was not completed until August 4, 2025 and submitted on August 5, 2025. During interview, the RNAC confirmed that both discharge MDS assessments should have been completed within 7 days of the discharge start date and submitted within 7 days after completion, and acknowledged that both were completed and submitted late.
Failure to Provide Ordered Cervical ROM
Penalty
Summary
The facility failed to provide services to maintain and prevent further deterioration of functional status for Resident R93. The resident was admitted with a diagnosis including Cervical Disc Disorder with Myelopathy and Lumbar Region involvement. An OT discharge recommendation dated May 29, 2025, included cervical ROM, but the clinical record contained no documented evidence that cervical ROM was provided. The Director of Rehab confirmed that the resident was discharged from OT with recommendations for cervical ROM, and the DON confirmed that the facility did not have a Restorative Nursing Program and was just beginning to develop one, with no documented evidence that the cervical ROM was performed.
Dietary Restrictions and Allergies Not Followed
Penalty
Summary
The facility failed to ensure that resident food allergies and preferences were honored for two residents. One resident had diagnoses including diabetes, seizure disorder, anxiety, and bipolar disorder, and had a BIMS score of 15 indicating intact cognition. That resident’s record documented allergies to strawberries and tree nuts, and the lunch ticket for August 19, 2025 listed a regular consistent carbohydrate diet with allergies to strawberries, nuts, and seeds. During lunch observation, the resident was served cake with icing even though the resident questioned what kind of cake it was, stated he was allergic to all nuts, and declined the cake after smelling it. The nurse aide who served the cake said she did not know what kind of cake it was, and no alternative dessert was offered. The Food Service Manager confirmed the resident should not have been served the cake and stated the cake had been improvised and was not specifically listed on the menu or documented as a change. The facility also failed to follow another resident’s physician diet order that prohibited beef, pork, and straws. The resident’s diet order dated July 14, 2025, included those restrictions, yet on August 18, 2025 the resident was observed receiving a lunch tray with a water cup and straw. On August 20, 2025, the resident was again observed receiving a lunch tray that included pork over rice and water with a straw. An LPN confirmed at the time of observation that the meal was served despite the diet restrictions.
Non-Functional Call Bells in Resident Rooms
Penalty
Summary
The facility failed to ensure that call bells were functioning properly for two residents. Resident R73, who had diagnoses of pain in an unspecified knee and difficulty walking, was observed in bed wearing a gown and yelling for help. The call bell outlet on the wall to the left side of the bed had two prongs attached, but one prong had no cord and the other had a cord cut 3 inches from the prong. Resident R106 was observed in bed wearing a gown and sleeping, and the call bell outlet on the wall to the left side of the bed also had two prongs attached, with one prong lacking a cord and the other cord lying on the floor. The second floor Unit Manager confirmed at the time of observation that the call bells for both residents were non-functional.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that Department of Health survey results were readily accessible to residents and visitors on three nursing units, including the 1st, 2nd, and 3rd floors. During a resident group meeting, eleven alert and oriented residents stated they were not aware of where the survey results binder was located or available for review. An observation later showed the survey binder in the main lobby in a black unlabeled binder hanging on the wall, and further review with the Nursing Home Administrator confirmed the binder did not contain any survey results beyond February 2, 2024. The Nursing Home Administrator also confirmed that the state survey results were not readily accessible for residents, families, and visitors to review.
Failure to Document Resident Interactions and Behavioral Events
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents with behavioral and mental health diagnoses. Specifically, the clinical records for two residents, both with histories of dementia, mood disorders, anxiety, depression, and bipolar disorder, did not reflect significant events and interactions that occurred between them. Although social services and staff were aware of a close relationship between the two residents, including kissing and being alone together in private areas, these interactions were not documented in the residents' progress notes over the past three months. Staff interviews confirmed that such events occurred, and that staff intervened and reported the incidents to nursing management, but there was no corresponding documentation in the clinical records. Additionally, the facility's policy on behavior management and monitoring was not followed as required, as evidenced by the lack of documentation regarding the residents' interactions and the behavioral concerns that prompted room changes and increased monitoring. The absence of accurate and complete records for these residents, despite their complex behavioral histories and the facility's awareness of their interactions, constitutes a failure to maintain medical records in accordance with accepted professional standards.
Failure to Develop and Implement Elopement Care Plan for Resident with Psychosis and Schizophrenia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing elopement risk for a resident with a history of psychosis and schizophrenia. The resident was admitted with significant mental health diagnoses, including psychosis and schizophrenia, which are associated with symptoms such as hallucinations, delusions, and disorganized thinking. Despite these risk factors, the clinical record review showed that no care plan was in place to address the resident's risk of elopement. On April 23, 2025, the resident was discovered missing from his room, prompting a search and notification of local authorities, facility administration, and the resident's guardian. The resident was later found at a local convenience store and returned to the facility without injury. Interviews with the resident revealed ongoing dissatisfaction with the facility environment and food, as well as a stated intent to leave again if possible. The Administrator and DON confirmed that the care plan was not comprehensive regarding elopement prevention and resident safety.
Failure to Ensure Safe Beverage Temperatures and Proper Supervision
Penalty
Summary
The facility failed to ensure that hot beverages were served at safe temperatures, resulting in an Immediate Jeopardy situation for residents on the First Floor. The coffee was served at 178 degrees Fahrenheit, exceeding the facility's policy limit of 165 degrees. This led to Resident R97 sustaining a burn on the left hip after spilling the hot coffee. The resident, who had no cognitive impairments, required assistance with setup or cleanup for eating. The incident was not immediately addressed, as the nurse aide did not take the temperature of the coffee before serving it and was unaware of the facility's policy. Additionally, the facility failed to properly supervise Resident R9, who had a history of respiratory failure, dysphagia, and other conditions, resulting in actual harm. The resident, with moderate cognitive impairment, was on a mechanical soft diet but consumed a hoagie, leading to a choking episode that required the Heimlich maneuver. The resident subsequently developed aspiration pneumonia. The care plan for Resident R9 included supervision during meals, which was not adequately provided, allowing the resident to eat food not in accordance with diet orders. The facility's lack of adherence to its policies and inadequate supervision of residents led to these incidents. The dietary and nursing staff were not aware of the temperature requirements for serving hot beverages, and the supervision of residents with dietary restrictions was insufficient, resulting in harm to Resident R9. These deficiencies highlight the need for strict adherence to safety protocols and proper supervision to prevent accidents and ensure resident safety.
Removal Plan
- Facility reviewed and updated the hot liquids policy.
- Prior to hot liquids leaving Dietary, a temperature will be taken by Dietary staff.
- Before serving to residents a temperature will be taken by CNA (nurse aide)/Nurse and be documented.
- If the hot liquid temperature is > 150 degrees, it will not be served and will be cooled down by using ice until the temperature is below 150 degrees.
- The facility will inservice more than 90% of staff and will be at 100%.
- The facility will do audits to ensure effectiveness of staff in-service using questionnaire and/or on the spot interview and results to be reviewed in QAPI.
- The facility to audit temperature daily for one week and twice a week for two weeks and weekly for two months and reported and discussed in QAPI.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards of practice in two out of three medication storage rooms observed. On the 2nd floor unit, an eye drop medication, Latanoprost 0.005%, which required refrigeration before opening, was found in the medication cart instead of being refrigerated. This finding was confirmed with a licensed nurse, Employee E18. Additionally, on the 3rd floor unit, an expired nutritional supplement, Glucerna with carb steady, was found with an expiration date of November 1st, 2024, and was intended for a resident who had not yet received it. Further inspection revealed 19 more expired nutritional supplements in an unsealed box in the medication storage room. The facility's policy mandates that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, observations on the 2nd floor unit revealed several expired medications, including Vitamin B-6, Diphenhydramine Hcl, Reguloid, Bisacodyl suppository, Major sore throat spray, and Zinc Sulfate. These findings were confirmed with the Unit manager, Employee E19. Similarly, on the 3rd floor unit, expired medications such as Mommy's bliss - baby gas relief - Simethicone drops were found, confirmed with licensed nurse, Employee E20. The facility's failure to adhere to its medication storage policy resulted in the presence of expired and improperly stored medications.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances and concerns raised by residents, as evidenced by interviews, clinical records, and resident council minutes. Eleven residents attending the resident council and two additional residents had unresolved issues related to billing clarification, the status of the activity van, room change requests, and missing items. The facility's grievance policy mandates attempts to resolve concerns within three business days, with unresolved issues reported to the Nursing Home Administrator (NHA). However, this policy was not effectively implemented, as residents reported delays and lack of communication from the social worker and other staff. Resident R26, who was admitted with a primary diagnosis of heart failure, expressed frustration over the lack of response from the social worker regarding a request to share a room with her husband, Resident R80. Despite being informed that they would be placed together when a room became available, there was no follow-up, and the resident's missing orthopedic shoe further complicated her care. Occupational Therapy notes indicated that the missing shoe hindered her ability to transfer, yet the issue remained unresolved, with the resident being advised to purchase new shoes. Resident R41, diagnosed with multiple sclerosis, also experienced communication issues with the social worker regarding billing concerns. The resident disputed claims of making appointments that incurred charges to the facility and requested to see the bills, but received no response. Additionally, residents expressed dissatisfaction with the lack of updates on the activity van, which had been out of service since March. The NHA acknowledged the van's status but had not communicated this to the residents, leading to further grievances. The facility's failure to address these concerns violated resident rights as outlined in 28 Pa. Code 201.29(a)(i).
Failure to Provide Timely Podiatry Care for Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, Resident R26 and Resident R41, as per professional standards of practice. Resident R26, who was admitted in November 2020, has diagnoses of heart failure and Type II Diabetes, which can increase the risk of foot injuries due to nerve damage. Despite being alert and oriented, Resident R26 reported not being seen by a podiatrist since a scheduled appointment on July 10, 2024, which recommended follow-up treatment in 60 days. However, there was no evidence of any further podiatry appointments in the resident's clinical records. Similarly, Resident R41, admitted in September 2021 with multiple sclerosis, which can cause numbness and pain in the feet, also reported not receiving timely podiatry care. The last documented podiatry appointment for Resident R41 was on July 10, 2024, with a recommendation for follow-up treatment in 60 days. The facility's failure to schedule further podiatrist appointments for both residents was confirmed by the Director of Nursing on November 15, 2024, indicating a lapse in maintaining the residents' foot health as required by professional standards.
Insufficient Nursing Staff Leads to Choking Incident
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the safety of residents, specifically impacting one resident, identified as Resident R9. This resident has a complex medical history, including dysphagia, bipolar disorder, Parkinsonism, and schizophrenia, which necessitates special dietary and supervision needs. On July 15, 2024, Resident R9 experienced a choking incident while eating a hoagie in the dining room, despite having a physician's order for a mechanical soft diet. The incident required the Heimlich maneuver and resulted in a diagnosis of aspiration pneumonia, for which the resident was treated with antibiotics. The investigation revealed that Resident R9 was not properly supervised during the meal, as the facility did not have enough nursing staff to oversee residents with behavioral health needs. The resident's care plan, which identified a risk for choking and aspiration due to dysphagia, included interventions for supervision during meals. However, these interventions were not implemented until after the choking incident. An interview with a licensed nurse confirmed the lack of sufficient staff to supervise residents adequately, leading to the deficiency cited under F 689 and relevant state codes.
Failure to Manage Hot Beverage Temperatures Leads to Resident Burn
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to manage the facility effectively, leading to an Immediate Jeopardy situation. The deficiency involved serving hot beverages at unsafe temperatures, resulting in a burn injury to a resident. The facility's policy on hot liquid management, which required coffee to be served at temperatures not exceeding 165°F, was not adhered to. Observations revealed that coffee was being served at temperatures as high as 182.8°F, and staff were unaware of the policy or how to check the temperature before serving. The incident involved a resident with no cognitive impairments who accidentally spilled hot coffee on himself, resulting in a blister on his left hip/buttock area. The resident required treatment with Silvadene cream. Staff interviews confirmed that the temperature of the coffee was not checked before serving, and the dietary and nursing aides were not aware of the facility's policy regarding safe serving temperatures. The Nursing Home Administrator acknowledged the oversight and the potential risk it posed to residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy revised in June 2023. This policy mandates the use of gowns and gloves during high-risk activities for residents colonized or infected with targeted or epidemiologically important multidrug-resistant organisms (MDROs). During an observation tour on November 19, 2024, it was noted that there was no enhanced barrier precaution signage or personal protective equipment (PPE) available for four residents with specific medical conditions that necessitated such precautions. These residents included one with a Foley catheter for hydronephrosis and urinary retention, another with a feeding tube, a third with a foot ulcer and osteomyelitis requiring a PICC line for intravenous antibiotics, and a fourth with a chronic eye infection. Additionally, the facility did not provide enhanced barrier precaution signage for two other residents who were on barrier precautions. One of these residents had carbapenem-resistant enterobacterales, and the other had a Foley catheter, Candida auris, and a sacral pressure ulcer. An interview with the Registered Nurse Assessment Coordinator and Infection Preventionist confirmed the lack of implementation of the facility's policy, as there was no signage or PPE provided for the residents mentioned. This deficiency was noted under the Pennsylvania Code regulations regarding the responsibility of the licensee and nursing services.
Water Temperature Deficiency Across Facility Floors
Penalty
Summary
The facility failed to maintain safe and comfortable water temperatures for residents, staff, and the public across all three floors. During a group meeting with 11 residents, two residents from the second floor reported issues with water temperature fluctuations, with one resident experiencing a sudden increase in water temperature while showering. An interview with the Nursing Home Administrator revealed that the facility lacked a specific policy on water temperatures, relying instead on state regulations of 110 degrees. However, surveyors recorded water temperatures exceeding this limit, with readings of 115.5 degrees on the first floor and 112.4 degrees in the third-floor shower room. The second-floor shower room registered a temperature of 106 degrees, which changed to colder when the faucet was slightly adjusted. The Maintenance Director identified the need for a new regulator for the faucet.
Unlicensed Staff Completing MDS Assessments
Penalty
Summary
The facility failed to ensure that staff completing the Minimum Data Set (MDS) were properly licensed and registered to practice nursing in Pennsylvania. Employee E15, who works remotely from outside the United States, was found to have completed and signed multiple sections of the MDS for several residents without holding a valid nursing license in Pennsylvania. The Pennsylvania Licensing System Verification website confirmed that Employee E15's name was not listed in the database for nurses licensed to practice in the state. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness and documentation regarding Employee E15's licensing status. The Director of Nursing acknowledged that Employee E15 worked remotely and did not have a copy of her nursing license. The Administrator initially claimed that Employee E15 was performing clerical work and did not require a license, but later admitted that she had completed assessment portions of the MDS. An interview with another RNAC confirmed that Employee E15 completed some sections of the MDS, which were then verified by the RNAC.
Failure to Provide ASL Translation for Resident's Representative
Penalty
Summary
The facility failed to provide American Sign Language (ASL) translation for a resident's representative during a care plan meeting, which is a violation of the resident's right to receive notices in a format and language they understand. The resident, who was admitted with multiple diagnoses including Dysphagia, Anxiety, Type 2 Diabetes, and others, had a Power of Attorney (POA) for medical care. The resident's daughter, who is deaf and uses sign language, required an interpreter for the care plan meeting. However, the facility's policy did not accommodate this need, as they stated they would only provide translation services if the resident themselves required it. Interviews with facility staff, including the Social Worker and Nursing Home Administrator, revealed that the facility was aware of the representative's need for a translator but chose not to provide it due to associated costs. The facility communicated with the family member through writing when she was present at the facility, but did not provide a sign language interpreter for the care plan meeting. The family member declined to use her own interpreter over the phone, leading to the deficiency in communication during the care planning process.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long Term Ombudsman of facility-initiated emergency transfers and discharges for three residents. Resident R10 was discharged to the hospital and did not return after hospitalization. Resident R8 was discharged to the hospital, was cut off by insurance, and did not return. Resident R9 was discharged to the hospital, readmitted, and then discharged again, not returning after the second hospitalization. The facility documentation lacked evidence of notification to the Ombudsman for these discharges. An interview with the Nursing Home Administrator revealed that the facility did not have a process in place for providing the Ombudsman with discharge notices.
Non-Functioning Air Conditioning Units in Facility
Penalty
Summary
The facility failed to ensure that the air conditioning units (PTAC units) were functioning properly across all three nursing units, including the 1st, 2nd, and 3rd floors. During observations conducted with the Maintenance Director, several PTAC units in resident rooms and dining areas were found to be non-functioning. Specific issues included units not blowing cool air, units with front panels hanging off, and units that were completely non-functional. Residents confirmed that their rooms felt warm, indicating discomfort due to the malfunctioning air conditioning units. The facility documentation review further revealed that multiple PTAC units required repairs, such as cooling section replacements, control box installations, and front cover repairs. The deficiencies were confirmed with the Maintenance Director during the observations. The report cites violations of 28 Pa Code 201.14 (a) and 28 Pa. Code 201.18(b)(1), which pertain to the responsibility of the licensee and management, respectively.
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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 | 0.2 mi | ★★★★★ | 4 | 0 |
| St Mary Center For Rehabilitation & Healthcare | 0.8 mi | ★★★★★ | 15 | 0 |
| Montgomeryville Skilled Nursing And Rehabilitati | 2 mi | ★★★★★ | 0 | 0 |
| Gwynedd Healthcare And Rehabilitation Center | 2 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.