Harborview Rehabilitation and Care Center at Lansd

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served and maintained under sanitary conditions for one of five residents reviewed for nutrition. (Resident R39)

Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to include the needs of its bariatric resident population in the facility assessment, which is required to ensure the facility has the necessary resources to provide person-centered care.

Inspectors wroteBased on reviews of staff training and competency sets for nurse aides, reviews of the facility assessment and interviews with staff, it was determined that the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for 16 nursing assistants employed since the last review period. [...]

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to ensure that all residents at the lunch table were provided their meals at the same time and failed to ensure resident's dignity on one of five dining rooms observed. (First Floor)

Inspectors wroteBased on a review of clinical records, review of facility documentation, and staff interview, it was determined that facility failed to timely provide notices of Medicare non coverage (payment) for two out of six residents reviewed (Residents R126, R31). Findings Include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. Review of facility documentation revealed Medicare services ended for Resident R126 on April 2, 2025; Medicare services ended for Resident R31 on April 30, 2025. [...]

Inspectors wroteBased on observations, interview with residents and staff and interview conducted during resident group meeting, it was determined that the facility failed to provide a clean, comfortable, homelike environment for one of 25 residents reviewed (Residents R56). The facility failed to provide a locked drawer for personal belongings for twelve of twelve residents reviewed (Residents R56, R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19).

Inspectors wroteBased on a resident group interview, tour of the facility and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents for anonymous submission on two of three nursing units (2nd floor and 3rd floor nursing units). Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (Residents R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19) who reported residents were unaware of where the grievance forms were located. The residents were unaware of location of grievance/concern submission boxes to submit an anonymous grievance. On August 19, 2025, at 11:40 a.m., a facility tour was conducted with the Nursing Home Administrator, Employee E1. [...]

Inspectors wroteBased on review of clinical record and interview with staff, it was determined that the facility failed to complete and submit a MDS (Minimum Data Set- a federally required assessment completed at a specific interval) discharge tracking for two of two resident records reviewed. (Resident R121 and Resident R29)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan related to range of motion and dental needs for one of 25 residents reviewed (Resident R93).

Inspectors wroteBased on observation, review of clinical records and interview with staff, it was determined that the facility failed to provide services to maintain and prevent further deterioration of functional status for one of 25 residents observed. (Resident R93)

Inspectors wroteBased on observation, clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a resident preference was honored and to accommodate resident's allergies for two of 25 residents reviewed. (Resident R23 and Resident R39)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that call bells were functioning properly for two of 25 residents reviewed. (Resident R73 and Resident 106)

Inspectors wroteBased on observation and an interview with staff and resident group meeting, it was determined that the facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (1st floor, 2nd floor and 3rd floor nursing units)Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19 ) who reported that they were not aware of the location where the survey results binder would be located and available to review. Observation on August 19, 2025, at 11:35 a.m. revealed the survey binder was in the main lobby in black unlabeled binder hanging on wall. [...]

Inspectors wroteBased on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for two out of eleven residents reviewed (Resident R6 and R7). Findings Include: Review of the facility policy, Behavior Management Program Overview, Overview-The facility promotes the utilization of a behavior intervention and management program based on individual resident/patient needs. Review of Resident R6's clinical record revealed Resident R6 was admitted to the facility on [DATE] with a diagnosis of: Unspecified Dementia, Mood Disorder, and Anxiety Disorder. Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of Anxiety Disorder, Depression, Bipolar Disorder. [...]

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans related to elopement for one of eight residents reviewed. (Resident R1).

Inspectors wroteBased on review of clinical records, resident and staff interviews, review of facility policies and documentation, it was determined the facility failed to ensure a hot beverage was served at safe temperatures on one of three nursing floors (First Floor). This failure placed 23 of 24 residents on the First Floor in an Immediate Jeopardy situation where the temperature of the hot coffee was 178 degrees Fahrenheit. Further, the failure to ensure that hot beverages were served at safe temperatures resulted in Resident R97 sustaining a burn on the left hip for one of 25 residents reviewed. The facility also failed to properly supervise Resident R9 resulting in actual harm when Resident R9 consumed foods not in accordance with diet orders, experiencing a choking episode, which required the Heimlich maneuver, and developed aspiration pneumonia for one of 25 residents reviewed. (Resident R9).

Inspectors wroteBased on observations, review of facility policy and interview with staff, it was determined that the facility did not ensure drugs and biologicals were stored according to professional standards of practice for two out of three medication storage rooms observed (2nd floor and 3rd floor unit medication storage rooms)

Inspectors wroteBased on interviews with residents and staff, review of clinical records, review of monthly resident council minutes and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns elated to, billing clarification, status of the activity van, request for room change and missing items for 11 of 11 residents attending resident council (Residents R10, R12, R16, R17, R38, R52, R66, R79, R90, R91 and R101) and two of 25 resident records reviewed (Resident R26 and R41).

Inspectors wroteBased on interviews with residents and review of clinical records, it was determined that the facility failed to ensure residents receive proper treatment and care to maintain good foot health in accordance with professional standards of practice for two of 25 residents reviewed (Resident R26 and R41).

Inspectors wroteBased on review of facility provided documentation, and interview with staff, it was determined that facility failed to provide sufficient nursing staff to assure resident safety for one of 22 residents reviewed (Resident R9)

Inspectors wroteBased on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation related to ensure that a hot beverages was serve at safe temperatures resulting in a burn to the resident (Resident R97).

Inspectors wroteBased on observation, interview with staff and review of facility policy, it was determined that the facility did not implement enhanced barrier precautions for four residents (Residents R97, R59, R36, and R17) and no enhaced barrier precaution signage for two of six residents on barrier precautions. (Resident R10 and Resident R103).

Inspectors wroteBased on interviews with residents and staff and facility documentation, it was determined that the facility did not maintain a safe, and comfortable water temperatures for residents, staff and the public for three of three floors. (1st, 2nd and 3rd floor)

Inspectors wroteBased on a review of facility documentation, personnel records and interviews with staff, it was determined that the facility failed to ensure that staff completing the MDS (Minimum Data Set, comprehensive resident assessment) were properly licensed and registered to practice nursing in Pennsylvania for one of ten personnel files reviewed. (Employee E15)

Inspectors wroteBased on review of facility policy, review of the resident clinical record, and interviews with staff, it was determined that the facility failed to provide American Sign Language translation for a resident's representative as required for a care plan meeting for one of eleven residents reviewed. (Resident R11) Findings Include: Review of the facility policy titled Baseline Care Plan undated states, Intent- It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the office of the State Long Term Ombudsman of facility initiated emergency transfers and discharges for three of three discharges reviewed. (Residents R10, R8, R9). Findings Include: Review of facility documentation (list of all facility- initiated discharges) revealed that Resident R10 was discharged from the facility to the hospital on June 16, 2024 and did not return after the hospitalization. Review of facility documentation (list of all facility- initiated discharges) revealed that Resident R8 was discharged from the facility to the hospital on July 15, 2024, was cut off by insurance, and did not return to the facility. [...]

Inspectors wroteBased on observation, resident and staff interviews and review of facility documentation, it was determined that the faciltiy failed to ensure that air conditioning units (PTAC units) were in functioning condition in 3 of 3 nursing units (1st, 2nd and 3rd floor)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to post how to file a complaint with the State Survey Agency as required for three of three nursing units. (First, second and third floor nursing)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that the results of the most recent survey of the facility, as well as any surveys, certifications and complaint investigations and any plan of correction during the preceding three years, were readily accessible and available for review as required on thre of three nursing floors. (first, second and third floor nursing units).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents' personal funds deposited with the facility.

Inspectors wroteBased on observations, review of clinical records and facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that clinical nursing staff, including licensed nurses and nurse aides, had specific and appropriate skills sets needed to provide resident care for four of five newly hired personnel files reviewed (Employees E15, E16, E17 and E18).

Inspectors wroteBased on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for two of two nurse aides reviewed as required (Employees E12 and E13).

Inspectors wroteBased on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide routine medications to meet resident needs for 3 of 34 residents reviewed (Residents R16 and R77)

Inspectors wroteBased on a review of facility documents and residents and staff interviews, it was determined that the facility failed to ensure that residents received services from a licensed barber.

Inspectors wroteBased on observations, review of facility polices, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection prevention for one of 25 residents (Resident R12) reviewed and the infection control program polices and infection committee meetings.

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for three of three nursing staff personnel files reviewed (Employees E11, E12 and E13)

Inspectors wroteBased on observations, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that an inventory of personal property was maintained for one of one residents reviewed related to personal inventories (Resident R16).

Inspectors wroteBased on interviews and the review of facility documentation, it was determined that the facility failed to ensure that the resident and her responsible party received written notification of all room changes before the room change occurred for 1 out of 25 residents reviewed (Resident R106).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a guardian's request to deny visitation was respected for 1 out of 25 residents reviewed (Resident 102).

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that resident had access to private telephone for 2 out of 25 residents reviewed (Resident R27 and R109).

Inspectors wroteBased on observations and resident interviews, it was determined that the facility failed to ensure that bed linens were maintain in clean sanitary condition for for 1 out of 25 residents reviewed (Resident R60).

Inspectors wroteBased on observations, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents had access to grievance forms, access to the contact information of the grievance official, and failed to ensure that grievances were appropriately resolved for 2 of 34 residents reviewed (Residents R16 and R13).

Inspectors wroteBased on observations, review of facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to report allegations of abuse, neglect and misappropriation within required timeframes for 3 of 34 residents reviewed (Residents R47, R13 and R16).

Inspectors wroteBased on interviews, and review of clinical records and facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was conducted for allegations of abuse/neglect/misappropriation of resident property for 2 out of 25 residents (Resident R13 and R16).

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that MDS assessments accurately reflected residents' status related to respiratory and diabetic care, for two of 34 residents reviewed (Residents R21 and R82).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care for one of 34 residents reviewed (Resident R21).

Inspectors wroteBased on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise a resident's care plan for recurrent fall prevention, for one of 27 residents reviewed (Resident R3).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to blood sugar monitoring, acupuncture services, and refusal of medications for three of 34 residents reviewed (Residents R21, R102 and 106 ).

Inspectors wroteBased on observations, resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure that proper foot care was provided to residents for 2 out of 25 residents reviewed (Resident R57 and R94).

Inspectors wroteBased on observations, review of clinical records and facility documentation, and interviews with residents and staff, it was determined that the facility failed to provide proper continence care for one of 34 residents reviewed (Resident R47).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure the proper storage of tube feeding formula and supplies for one of two residents reviewed for tube feedings (Resident R91).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with necessary behavioral healthcare, to maintain the highest practicable mental and psychosocial well-being, for one out of 27 resident records reviewed (Residents R69).

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse were disposed properly.

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure complete and accurate documentation for clinical records for 1 out of 25 residents reviewed (Resident R13).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective quality assurance and performance improvement program (QAPI) that includes actions taken aimed at performance improvement and program systematic analysis as required.

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents were offered Pneumococcal vaccinations as required for one of five residents reviewed. (Resident R30).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that call bell systems were accessible to residents for 1 out of 25 residents reviewed (Resident R102).

Inspectors wroteBased on review of facility documentation, observation, and interviews with staff, it was determined that the facility failed to maintain an adequate supply of emergency water. Findings Include: An initial tour of the Food Service Department, conducted on February 5, 2024, at 9:32 a.m., with the Dietary Manager, Employee E21, revealed the following concerns: Facility had not maintained a three-day supply of emergency water on-site. An interview with Dietary manager, Employee E21, at the time of the finding, confirmed that the Facility had not maintained a three-day supply of emergency water on-site. 28 Pa Code: 201.18(b)(1)(3) Management 28 Pa Code: 211.10(a)(b)(c)(d) Resident care policies 28 Pa Code:

Inspectors wroteBased on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 was free from sexual abuse. This failure resulted in an Immediate Jeopardy situation for Resident R1, who was sexually abused by Resident R8 for one of eight residents reviewed. (Resident R1) Findings Include: The facility policy titled, Policy: abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation revised October 16, 2018, states, It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and the taking of pictures/videos with resident consent. [...]

Inspectors wroteBased on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to develop a plan of care for a resident who exhibited sexual behaviors (Resident R8). This failure resulted in Resident R8 sexually abusing Resident R1 and placing Resident R1 in an Immediate Jeopardy situation, for one of eight residents reviewed. (Resident R1) Findings Include: [...]

Inspectors wroteBased on clinical record review, review of facility documents and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation in a timely manner for an allegation of sexual abuse for one of eight residents reviewed (Resident R1).